Ins. refusing to pay for Humira


Posted by: Es mom , Apr 17,2008,00:05  


Our wonderful insurance has denied payment for Humira citing E's age as the reason. We have 10 days to do a quick appeal- dr's letter stating medical necessity - before the final appeal. HELP! How did your doctors get Humira approved?

Em is in a full flare along with SURPRISE! 2 fistuals. They are draining,so thankfully nothing surgical needed. She is going to the bathroom soooo many times! It's hard to keep track. The only positive is that she has gained 5 lbs, thank you prednisone.

Please keep our family in your thoughts and prayers, especially Em.

Dina
E, 11 years. Current meds- Pred 30mg, 6MP, Cipro, Flaygll, Miralax, Culturelle- the double dosing of Remicade every 6 weeks failed, she has the antibodies.

Replies:
Re: Ins. refusing to pay for Humira

Re : Ins. refusing to pay for Humira --- Es mom
Posted by: Allyson , Apr 17,2008,16:23 Top of Thread


We recently just had this problem, denied for age. It took me many hours on the phone. Really the only thing that made it go any faster than the regular appeal process with our ins. company was getting in touch with a medical director from the insurance company. Then he had to be the one to figure out what to do next, who to contact and how to get the computer system to show approved for the pharmacy to fill it! Good luck!!
Allyson

Re: Ins. refusing to pay for Humira

Re : Ins. refusing to pay for Humira --- Es mom
Posted by: cals mom , Apr 17,2008,11:31 Top of Thread


Everyone has given you great advice. We also had our doctor fax in a letter. However, another thing that helped was I contacted my Congressman and State Senator. They also sent communication to the insurance company. Luckily my Senator, Kit Bond, is on the Subcommittee on Public Sector Solutions to Global Warming, Oversight and Children's Health Protection.
So...keep calling the insurance company and find out exactly who to direct communication to. Have your doctor send a letter. Call your Senator. Also, a lawyer from the Missouri chapter of the CCFA offered to communicate with the insurance company as well. Luckily the overturned their decision about Remicade.
Good luck. You will win.
Diane
Cal, 17, CD, Humira

Re: Ins. refusing to pay for Humira

Re : Ins. refusing to pay for Humira --- Es mom
Posted by: kmap , Apr 17,2008,10:50 Top of Thread


we went through a very similar situation about a year ago. get on the phone to your insurance company and start pleading your child's case. it took me a lot of phone time, but i finally got to people high enough up that their opinions regarding my case mattered. i tried to only talk to the board certified people and pharmacists that work for my insurance co. i told them to put themselves in my place. if it was their child, wouldn't they invest the money to fix the problem? who were they to decide whether or not my child should be allowed to feel better and improve his quality of life? it helped. make sure that you comply with the paperwork deadlines, too. but i do think adding the personal info from parents helps.
good luck!
kmap

Re: Ins. refusing to pay for Humira

Re : Ins. refusing to pay for Humira --- Es mom
Posted by: momof1 , Apr 17,2008,09:32 Top of Thread


This is so frustrating when I hear of these things. Like we would WANT to put our kids on these drugs if we had a choice!

My husband was admitted to the hospital just a few weeks ago for a heart problem. The ins. sent us a letter a week after he was released to tell us that they were not going to pay for him to stay at the hospital or treatment he received because they didn't think he should have been admitted! Huh? I think they will change their minds.

ANyway, that's not helping you. But, I sympathize even if I can't provide any help. Sorry.

I will put you and your daughter in my prayers. You've already gone through so much.

Jeanette

Re: Ins. refusing to pay for Humira

Re : Ins. refusing to pay for Humira --- Es mom
Posted by: momof2boys , Apr 17,2008,08:47 Top of Thread


hang in there.....i went through the same battle with remicade approval..........it took a doctor letter of medical necessity, and doctors records.......and lots of follow up phone calls,,,and finally it was paid........I know it's hard,but you will win in the end. I know you are asking about Humira, but if you go to remicade's website you can download a sample medical necessity letter. Hope this helps,,,

Re: Re: Ins. refusing to pay for Humira

Re : Re: Ins. refusing to pay for Humira --- momof2boys
Posted by: Es mom , Apr 17,2008,10:46 Top of Thread


Life is not fair, but I have faith that it will be paid. It is just really hard to stomach seeing your child suffer. Thank you for your help and thoughts. WIshing your family good health.

Dina