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I'm stuck in a Kafkaesque situation w/my insurance company (Anthem). I currently get infusions of a biologic for Crohn's. These are incredibly expensive as we
by thow16161 2y ago
I'm stuck in a Kafkaesque situation w/my insurance company (Anthem). I currently get infusions of a biologic for Crohn's. These are incredibly expensive as well as inconvenient. I'm lucky, in that my insurance company pays for almost all of this.
The same drug is now available in the form of a self-administered pen which is far less expensive and more convienient. However, that falls under the purview of CVS Caremark, who Anthem has designated as its pharmacy benefits manager. CVS Caremark is denying the pen, saying I have to try a whole host of other meds which do not work for me first.
I talked to Anthem yesterday, and they have no idea how to get this approved. Their best suggestion is that my doctor schedule a call with the CVS doctor to argue with them. My doctor is not motivated to do this, as I'm already getting a treatment that works for me.
So I'm stuck wasting hours every few weeks for an infusion that could be replaced by an injection I give myself. And the hilarious part is that the insurance company stands to benefit the most, as they would pay far less.
This is the kind of thing that, if we had actual socialized medicine, I might be able to appeal to a government official to fix. But how can you appeal corporate bureaucracy?
- ericmcer 2y agoI don't know if the ease and speed at which government officials fix things is a compelling argument for socialized medicine.
- bfrankline 2y agoYet people love Medicare and Medicaid.
- Schiendelman 2y agoYou are probably best off just not fighting it. Keep getting the infusions. Stop worrying about it. Let the insurance company make a decision if they think they can save money.
- inkcapmushroom 2y agoHow I Learned to Stop Worrying and Love the Injections.
- BugsJustFindMe 2y agoYou must have missed the part where the other treatment isn't just cheaper but also notably better for their quality of life. Telling someone to just stop worrying about it is awful.
- Schiendelman 2y agoOooh I did miss that! Shit.
- BugsJustFindMe 2y agoI just want to throw into the thread that a family member who was also getting injections had their Crohn's go into full remission after they started taking low dose naltrexone, which as a pill is both cheap and easy to self-administer even without insurance coverage. Maybe you've already explored in that direction, but if not, N=1 it appears to have been miraculous.
- Henchman21 2y agoSend, via registered letter, a request for the following: - the name, license #, and board-specialty of the physician making this determination - copies of all materials used to make this determination - proof the doctor making this determination has maintained registration in your specific state and documents proving they meet all their continuing education requirements - the aggregate rate at which this specific condition is denied or approved by this specific doctor making your determination Registered letter to CVS Caremark legal department. What they’re doing its blatantly illegal. You are entitled by law to this information and if they cannot provide it they must approve your treatment. (YMMV, I haven’t had the opportunity to try this, though it comes highly recommended from a physician’s assistant who deals with this bullshit endlessly)