Need help now- insurance company fight UPDATE

My doctor decided to join the mayo's treatment plan but now my insurance company is denying me the use of methotrexate unless I take humira or remicade with it.

Has anyone heard of this? My doctors are flabbergasted. They don't understand. If I can't get the methotrexate, which is better.. humira or remicade...

I am in tears... this is so ridiculous.

Btw, I think you will win the fight against the insurance company. I noticed you had pancreatitis due to Humira, so that is a risk factor for you they can't ignore.

They don't have a leg to stand on, from the standpoint of written therapeutic guidelines for Crohn's ...The insurance company might be going by guidelines more appropriate for arthritis than Crohn's.

If you are following a Mayo protocol, who are they to disagree with the top Crohn's docs in the country?

 

My guess is they think the combo might be more effective than just one med, alone. My other guess is they are just looking for an excuse to deny you.

Their decision needs to be based on mainstream medical science - clinical trials showing evidence that combos are definitely better than meth, alone. I haven't been able to find any research that shows clear evidence, from a clinical trial, that a combo of meth-humira or meth-remicade is better than meth alone.     

As the article showed, at one time, for instance in 2006, there were top docs who thought methotrexate mixed with remicade might be more effective than just one of them, alone. But the research presented in 2008 let the medical profession know this combo is not more effective, at least not for Crohn's. 

Have you called the insurance company and asked it how to appeal the decision?

 

June: Sigh . . .its a sigh of sympathy . . . that you don't feel good and have layers of issues stacking up on you. Have you ever thought about calling your congressman? Seriously, that is what they are there for - you hired him/her by voting them into office and they interface the government and resources in the community. Soooo when the congressman's office calls, businesses sit up and pay attention- even wayward insurance companies. Granted they have no legal right to force a response - ie like the police and a lawbreaker. But the political will weights heavily and insurance companies are restricted to state boundaries for a reason (to be supervised by the state). So I say go for it, call and make an appointment. What can it hurt? They don't charge you and can give you some great advice.

about 3 years ago I was placed on methotrexate and remicade at the same time to help counteract the antibody buildup that was developing. It was a very effective combination for both the crohn's disease symptoms and the arthritis. It was considered pretty common practice around my area and on here there were multiple people doing the same thing. I would still be on the same regime but the methotrexate began messing with my liver levels and I had to come off of it. It is also pretty common practice to mix mercaptapurine with remicade or humira after you have been on the medication for a while. Has your doctor worked much with tnf inhibitor meds in the past? It is kinda funny that your insurance is requiring you to go on Remicade or humira first considering the cost difference to methtrexate. Methotrexate is not even 10% of the cost of my monthly remicade infusion.

They are requiring me to do both at the same time. The Mayo wants me to just do the methotrexate alone. My insurance company is requiring that I add Humira or Remicade to the treatment plan before they will pay for the methotrexate. It sounds crazy to me. I did so much research yesterday and last night.. I was finding articles both ways..including the one mentioned here.. that remicade and metho were not needed together... I am confused. They open in ten minutes and now I don't know what to do.. just go with the remicade and metho and see what happens?

From past experience, the insuranace companies don't really seem to care what your doctor says unless you just continue and continue to fight them.  They intentionally deny things because a lot of people just give in then and the insurance company gets out of paying.  I can't understand why they would require you to take 2 meds, when it would cost them a lot more, and it does seem like they are going more off of arthritis guidelines than Crohn's.  I know I've had to fight them on several occasions and it took a long time and a lot of doctor's justification.  Even then, their panel of "doctors" tried to say whatever my GI said was not correct.  We eventually won out, but it took a lot of paperwork and time. 

I don't remember the mtx costing much even at full price when I was taking it.  Can you not buy it on your own without going through insurance?

After a long day of talking to everyone in the insurance company, it looks like we have approval... YAY... the weird thing is that if we go to a private pharmacy it will be half the cost.. if we use the specialty pharmacy the insurance wants us to use, it will be way more expensive. For some reason the insurance company itself was confused over the "specialty drug" methotrexate but once that got sorted out, everything fell into place. Or so I hope. Tomorrow we are supposed to get the details of the pharmacy in town and when we start injections.

Ok Breathing... I am hoping that this does work for me. thank you , thank you .. so much. We used all the articles and made sure we educated the insurance company and it seemed to be effective.

thank you!!!!!

yay! Good for you!

June,
I am sorry I did not see this earlier. MTX cost's around 15 bucks (or less) a week (and has been around for alot longer then either remi or humira), both of those other meds cost several thousand. This is just insane that they would do that to you.
Hugs,
Navy

june:  you got some great directions and supportive literature.  There are usually ways around road blocks and impediments that people throw up.  I never really understand why the hoops have to be jumped through, its kinda like groundhog day where you keep doing the same thing over and over, trying to modify one small thing to acheive the desired outcome. So congratulations on sticking to you guns!  Victory is sweet!  Hope you feel better soon. 

You have the docs and evidence on your side, so it should be fine. Will keep my fingers crossed!