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Insurance denying Pentasa coverage

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Crohn's Disease
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Posted 2/28/2014 11:16 PM (GMT 0)
Hi everyone,

I have never posted but I read this forum often and I appreciate all of the insight and testimonials that I have been exposed to on this forum. I was diagnosed in 2011 with mild to moderate crohn's in the terminal ileum, confirmed by both colonoscopy and CT scan. I have been on Pentasa (8 pills per day) ever since and my GI doctor and I believe that I have done quite well on this. I have used Flagyl maybe 1-2 times/year for what my doctor considered a mild to moderate flair. In January of this year, I learned that my insurance will no longer cover Pentasa and is suggesting Lialda or Asacol. My doctor has written 2 appeals and they are still denying it. I was wondering if anyone is having any issues similar to mine. I am in North Carolina, 36 year old female. I have not done a lot of research on Lialda and Asacol but it was my understanding that they do not work in the small intestines. I am not sure what my next steps are; I just received another letter describing my ability to file a lawsuit. Yikes!

Any thoughts?

Thanks in advance.
Posted 3/1/2014 12:17 AM (GMT 0)
From the manufacturer of Lialda: "The tablet is coated with a pH dependent polymer film, which breaks down at or above pH 6.8, normally in the terminal ileum where mesalamine then begins to be released from the tablet core."

about Asacol: " releasing mesalamine in the terminal ileum and beyond for topical anti-inflammatory action in the colon."

about Pentasa:
"PENTASA is an ethylcellulose-coated, controlled-release formulation of mesalamine designed to release therapeutic quantities of mesalamine throughout the gastrointestinal tract."

So from this it would seem that Lialda or Asacol will both work as they are released in the area of your disease. All three medications have mesalamine as the main ingredient.
Posted 3/1/2014 2:20 AM (GMT 0)
I have had really good results with Asacol HD. I take 4800mgs a day.
Posted 3/1/2014 2:58 AM (GMT 0)
My apologies...the insurance company will cover Apriso (not Aasacol) and Lialda.
Posted 3/1/2014 3:31 AM (GMT 0)
You can have your doctor tell the insurance that you have been on the drug for an extended period of time and them changing drug coverage will interrupt your "continuity of care" and that may get them to approve it.
Posted 3/5/2014 6:18 PM (GMT 0)
Similar situation happened to me. I decided to give another med a try and not to fight the insurance company to keep covering Pentasa. So I switched to Sulfasalazine and within a few months I developed an abscess which became a fistula. If Pentasa is working for you, I say fight this with all you have. If I had known then what I do now, I would definitely have fought my insurance to cover it. Can't be sure the med switch led to the fistula's development, but seems likely because I was doing very well on Pentasa.

I'm surprised that the insurance is still denying it after the doctor's appeal letters. The older I get, the more I dislike insurance companies and their twisted ways.
Posted 4/23/2014 6:21 PM (GMT 0)
Hello,

I recently moved from IL BCBS to WA and am now with Aetna. Aetna is saying I should be taking a generic or different Brand of mesalamine. My Dr. does not want me to switch and I don't either. I have not had a flare up in over a year and my last colonoscopy was the best it's ever been. I emailed the FDA to ask about generics and they provided me with this:

"As indicated in our Drugs@FDA database under link http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.DrugDetails, there are no "Therapeutic Equivalents" or generic versions for Pentasa 250 mg or 500 mg."

I've decided I am not switching and am trying to get an appeal/exception. based on my research of Pentasa and how it treats my specific problems (most active in terminal ileum). Pentasa is formulated specifically to be extended release differently than the other brand names.

I had my Dr. fill out a precert form and have also sent over FDA information to Aetna to try to get them to cover Pentasa on a lower tier than they are now. Hope that helps. I don't think anyone besides my Drs or your Drs should be telling you what to take.

Krista - diagnosed September 2011, been on Pentasa 500 mg, 8 pills a day since diagnosis, also been on Entocort, prednisone, imuran.

currently only taking pentasa 500 mg, 8 pills a day and multivitamins
Posted 4/23/2014 11:14 PM (GMT 0)
Welcome Krista! Good for you for doing the research and jumping through the hoops, advocating for yourself!
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