Advise!! Please!

I posted a while back about Remicade being my next step...just found out this morning it was denied due to not trying Humira first. They just attempted to get prior authorization for the Humira, which was denied because I haven't been on prednisone for 2 months!
I've been on 4 Lialda a day, 60mg of prednisone, 500mg Flagyl three times a day, had mesalamine enemas (made me really sick), extra strength Tylenol, and Zofran for extreme nausea for just over a month now and I'm no where near better. Is this normal? I am still having 10-12 BMs a day, down from 30ish...I've dropped 20lbs...despite eating.
How long did everyone continue on prednisone and things like that to control a flare prior to transitioning to something else?

I had a boo-hoo session, but now I have to get this figured out- I can't take being sick like this for another month!

Yes, insurance is denying both right now!
I'm sure it comes down to cost of Humira vs. Remicade!

I have Cigna. The doctors office is filing an appeal for the Humira. They are okay with Humira if we can get it authd. I've pretty much decided that if they don't have approval for it tomorrow, I am going to the office and requesting to be seen by the doctor. I will request he admit me, then I can start the Remicade in the hospital!
I'm so pissed right now....and they are dumb because they are going to have a hospital stay to pay for because I've already met my deductible, instead of just paying for the med!!!!

Jc1973- my GI said that we didn't have time to wait for them to kick in because I have been so sick- which is why he jumped straight to the Remicade. But at this point, I wish I would have started them so at least I would have a week or so under my belt if I do have to wait the additional 4 weeks to start Humira and let the Prednisone run it's course!

Gary- I actually work for a Medicaid HMO. We do the same thing.
They are considered step therapy drugs, and you have to try certain methods before trying others. However, the problem lies in that they don't think through the process! For example- we have cancer patients get denied for a PET scan because they haven't had a CT in the last year- soooo...we pay for a PET and a CT, when we could have just paid for the PET! Huh?
Hospital admissions are the same way, you have to meet medical necessity to bed there, if not properly documented days of your stay can be denied for "lack of medical necessity!" Usually they use Interqual criteria to determine this. There are other intities, but that's the most common- Medicare and Medicaid abide by it most strictly, but most HMOs use the guideline as well.
That's why I'm fearful of admission again- I don't want to be denied hospital stay and be on the hook for the payment!
But at this point I do NOT care. I even considered charging the $4000 to my credit card and paying out of pocket for the Humira!
However, I really don't want to file bankruptcy!!

That was my only option. Luckily we just got bought out by a bigger company and we are changing carriers. They have different options!
I never gave it much thought- I am young, was always healthy, active, ate an 1800 calorie diet consisting of low glycemic carbs, protein, veggies and healthy fats. I recorded everyday what I are. I resistance trained 5 days a week and ran sprints 3 days a week....none of that exists anymore!
Lesson learned! Pay attention to you health coverage- even if you are healthy!

I went straight to Remicade after trying some 5-ASA's and 6MP.

Not to hijack this thread, but several years ago my wife and I were covered by Kaiser HMO for a year. During that time she went in for her annual well-woman check-up. No OB/gyn's were around so they brought in a pediatrician who literally looked through an instruction book during the examination to see how to do it. We switched back to our PPO as so as we were able.

Nursemb23, my good friend wrote this up for you, she has been dealing with employee benefits for about 5 years.

"Login to your CIGNA patient portal/account and download a copy of the insurance plans Evidence of Coverage/Summary Plan Description (EOC or SPD - terminology for this type of document varies by carrier but its usually one or the other), you can also call CIGNA and request them to mail you a copy. Its a long document written like a contract, not a several page summary - be specific if you call to request it because the CSR's tend to send out the plan summary instead of the full plan document. The EOC/SPD will tell you how to appeal a denial. Read the SPD to find out what the terms and conditions so you can familiarize yourself with the plans rules. This will help you to determine what you should include in your appeal letter. Request that the doctor give you the Remicade infusion and fight CIGNA's decision via their appeal process. Your doctor will need to explain in writing why he felt the Remicade infusion was "medically necessary" (i.e. delaying the Remicade infusion would have caused you to have to suffer in pain etc). If you need any help with the appeal process, please let me know."

Got it, my friend explained to me in that case it is called "step therapy". I can't believe they would force you into such a newly approved treatment for UC, but she then told me it is probably due to cost. Remicade is more expensive than Humira from what I hear. Anyway, I'm glad to hear you did get approved for the Humira at least! Hopefully it will work for you, if not, at least you can then try the Remicade. Goodluck with everything!

I hope Humira works for you.

I guess I am actually one of the very few here who have an HMO plan and love it. I have run into no issues with doctor visits, trips to the ER, multiple stays in the hospital, finding a specialist, medications (including my Remicade which I am lucky to only have to pay the $20 office co-pay and they did not fight me to start the Remicade) and tons of tests, both in the hospital and from the doctors office (blood work, stool samples, cat scans, x-rays, EKGs, echocardiograms, MRIs, ultrasounds). I also can't complain about my annual maximum.