Enbrel Claim Denied by Caremark

** Originally posted by ThomasF **

I have been responding very well to enbrel for the last 2 years. It is really the the best response I have ever had during a life time of psoriasis. I am almost totally clear. My employer's insurance (Caremark) has always covered enbrel. In fact, my last 2 insurance companies have covered it. Recently I got married and my wife and I decided to consolidate our insurance. Her pharmacy plan was also Caremark. Before switching I called caremark to make sure they would cover enbrel under her plan. I was told they would. On this basis I made the decision to switch. When my doctor called in the pre-approval yesterday he was told the claim was rejected and that I would receive a letter of explanation (something to the effect of alternative medication such as UV therapy should be explored).

So Caremark is forcing me quit enbrel cold turkey. I am p*ssed off of and a little depressed. I am trying to weigh my options (fight, try to get back onto my employer's insurance plan, some combination of both.) and understand potential risks (flare up from coming off the enbrel suddenly after 2 years).

I Would very much appreciate feedback and advice.

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3 replies. Join the discussion

** Originally posted by MikeK **

Hi Thomas,

Welcome to the board. :cool: Nice to meet you.

Congratulations on your recent marriage.

I'm sorry to hear that your new insurance company denied the pre-approval for Enbrel. :( :mad: Don't get mad, get even.

First, begin your new insurance company's formal appeal process. Today. Involve your doctor's office to greatest extent possible.

Second, call the NPF. They have an insurance advocacy service that goes to bat for people who are having insurance issues. Here's a link to their description of their service: http://www.psoriasis.org/advocacy/assistance/insurance/index.php and here's a link to their contact information: http://www.psoriasis.org/contact/. Call them today.

Third, give Enliven Services a call. They employ "insurance specialists" who assist patients with insurance issues: http://www.enlivenservices.com/pso/ongoingsupport/insurance/#q2. Call them today.

Fourth, as soon as you get the "denial of coverage letter" from you insurance company, file a formal (written) complaint with your state's insurance department or commissioner. Their contact information should be on your state's "official" website. (I live in New Jersey and this is what our official website looks like: http://www.state.nj.us/.) Most states and most insurance companies take the formal complaint process very seriously.

Finally, here's a link to a thread by PJ Leary; her insurance claim for Remicade (http://www.remicade.com) was denied by her insurance company and her experience may be helpful to you: http://www.psoriasis.org/forum/showthread.php?t=19225.

I hope this helps.

Hang in there!

Good luck. Keep us posted and please don't be a stranger.

Mike

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** Originally posted by wthiwwm **

I was denied Humira by Caremark. My rheum didn't want to wait to see how the appeal worked out so I was started on Remicade. By the time I had my second infusion, Caremark approved the appeal. When you get your denial letter, write an appeal letter to them and have your doctor do it to. Good luck!

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** Originally posted by KellyPSA **

I have Caremark as well thru Horizon BCBS and I feel tormented by them. My doc doesn't get to make my treatment decisions now, his clinical judgement is questioned by some petty bureacrat that problably has some company pharmaceutical training, but not much else.

I think they routinely deny first requests for everything...MTX which has been used for about 4o years for the treatment of RA,PSA and P,,,was denied for over 6 weeks. My real life pharmacist told me it costs about 30 dollars for a months worth. On principle, I waited for the process to take its course...Thy finally approved it,,,,I went thru hell for my annual preapprovals for Humira....Six weeks without....

In the mean time, I get sicker and need more drugs and more medical care,,,,I realy think its in their busines plan for docs and patients to just give up...I know my docs office is spending literally hours on the phone with Caremark and other insurance companies that supply Medicare Part D....I must admit, that before Medicare D, I was paying for a Medicare HMO that provided prescriptions and they were way easier to deal with before the government got involved....My statewide assistance for the pharmeceutical care is much more liberal in their coverage, but you need to get the Medicare D approval first even if they are not providing most of the care....I am too young to be disabled for life and I am trying really hard to get back to work...but these lapses in treatment cause set backs .

Sadly I feel like it doesn't make a difference who gets elected this year...I feel almost powerless in dealing with these issues....It seems mean spirited and very personal....I realize that its all just business...but their business plan makes me sicker and its very frustrating.

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