Humira... I was denied coverage by Great West Life

I don't understand why a life insurance policy is providing you health care? Or maybe Great West Life is a health insuror? And doesn't the Canadian NHS provide your meds within its own plan?

What Province are you living in?

If Ontario, you could apply to the Trillium fund. They will very likley cover the costs of Humira. Not sure, but I would think that there would be other organizations that would help cover the costs of this.

Tom.

I know how you feel. My GI wanted me to go on Remicade back in the late '90s, but his nurse informed me that the total cost due to the infusion being done in the hospital was running $12,000 per infusion for their patients. I knew the insurance we had wouldn't pay and even if they did, my copay would have been more than our income anyway. That insurance company would purposely mistype codes just to throw the claims out. I had to fight for every single bill to be covered and it got old.

We had Great West later and it was a big step up from what we had, but I never did Remicade or any other biologics, for various reasons including financial.

I'm not the breadwinner, but my husband who's 60, is having his own medical issues and we're just praying we can keep things going. And we have an adult daughter who had to stop everything due to an even worse medical problem and has been totally dependent on us for five years. She had been independent before that and worked hard and she isn't on disability. So I know how you feel.

That's great news Jamie!!!

Glad to hear that. I was going to suggest to keep insisting on coverage, whether via your insurance or Trillium. It's a shame that along with battling this dreaded disease, that we have to often fight so hard for appropriate care, treatment and in your case much needed coverage.

Tom.

Darn, I was looking forward to ribbing a Canadian about inadequate health care systems- don't usually get a chance to do that!


On a serious note, glad it worked out. I hope you see some improvement on Humira. It seems to help me, somewhat. Keeps me alive, anyway, which is always good.

Hmm. I'm in the same situation with Great West Life over Remicade. I've been denied twice after initially being told that I was covered. I can't afford it and I don't qualify for Trillium. I'm at the point where my work is suffering and I barely have enough energy to take care of my kid at the end of the day.

After a bad scan this summer, my doctor suggested that a biologic (specifically Remicade) was the only thing that would work for my situation (fistulizing Crohn's).

After two+ weeks of waiting for paperwork, Great West called on Friday and said that I had been rejected for a second time because I hadn't yet proven that other, cheaper drugs (immuran - which my dr said was not at all appropriate for my situation) and prednisone (which I'm currently on, and is not a long term solution) hadn't failed me yet. So what do you do - wait another 6 months and put more chemicals into your body knowing that they will do nothing for you, hoping that Great West will actually make good on their initial claim?

Insurance companies are more concerned with the bottom line than they are with the health and well being of their policy holders. What gives them the right to override the decision of your health care provider? It's all very frustrating.

Interesting the issue is with Great West. They just participated in the CCFC education symposium (in Toronto) where they talked about how they cover biologics on most plans. The woman was mosthy there to tell us to shop around to different pharmacies because the price is different whether you go to a Shoppers, Wal-Mart, Rexall, Costco, etc. I never thought about shopping around for lower prices.

I am glad they finally 'got it' harbinson66, and I totally get the stress. mtooke keep trying with the insurance company. Tell your doctor too, as sometimes the orders of why they are suggesting one med over another isnt clear. Insurance thinks they know better, but remember they are all in it to make $ somehow. Trying to still figure out how a paper pusher with maybe a 3-4 year degree would know more than a doctor who goes to school for 8-12 years, but still the paper pusher rules....

I don't have any advice for you. Just my sincere hope that you find some help.

Jamie

Thank you for the quick feedback. I am thinking about contacting the GWL ombudsman. It really bothers me that they are recommending a medication (methotrexate) that could be harmful to me in my current condition.

I just wanted to provide an update: after my gastroenterologist provided another letter, Great West Life (GWL) has approved me for Stelara.

Thanks to everybody for their feedback, my advice is to keep the communications channel open with your insurer and your doctor; although the process has taken months, I am very grateful for this result.

Be patient but also be persistent; having a great doctor and medical team supporting you makes a huge difference.

Take care.