Help please! Kaieser exception process

[andy58]

Help please! Kaiser and Entyvio (Vedolizumab)

Hi,
I'm new to the US and currently in my enrolment period at work for benefits. I am in the San Francisco Bay Area and was offered Kaiser HMO or Aetna PPO or HMO. I have 8 days left to make changes so your answers would be VERY VERY welcome.

Does anyone have experience with Kaiser Permanente approving non formulary drugs? More detailed question below.

I am currently on Humira (adalimumab) 40mg and methotrexate. I am on this after Imuran/azathioprine, mercaptopurine and infliximab have failed. So far so good BUT given my history I want to be prepared for a change. My doctor overseas told me if Humira fails too he will try Entyvio/vedolizumab (that was in England).

Kaiser seem to be the best option in my area with much higher raitings and reviews and I've heard a lot of good things about them. However, vedolizumab/entyvio is not on their formulary and my company's insurance broker said that this drug is
"Not on Kaiser's formulary. If your Kaiser Permanente physican determines through an exception process that it is medically necessary, it will be covered via Speciality Tier - $35 copayment"

So my question is,
What is the Kaiser process for approving non formulary drugs and is this likely to happen for a patient that failed everything else or does this never happen?

I am hoping this won't be needed but I want to use my enrolment period to move to Aetna (who do have this on the formulary!) just in case I need to leave Humira.

THANK YOU ALL!
Andy

 

[my little penguin]

From a Crohns perspective in the YS
Ppo reguardless tends to be better than hmo
HMO required a referral from your pcp every time you need to see a specialist
Which means each and every GI appt needs to have prior approval
Ppo you just schedule your GI appt no prior approval
Kaiser really restricts who you can see a lot more than ppo plans
Ppo plans you can go across the country if you need a second opinion outside your local area

 

[andy58]

Thank for replying but I meant to ask something else. I need to know about Kaiser exceptions and if anyone encountered this process with them.

And responding to you more generally, I realize PPOs are more flexible but they are also expensive and have higher deductibles and caps. I can save thousand of dollars by seeing a PCP once... Kaiser told me that their PCP only needs to approve me seeing a specialist the first time and then once I'm in the care of a GI for a chronic condition I don't need to see my PCP every time before regular GI checkups or care or prescription renewals.

 

[my little penguin]

After many years of dealing with healthcare in the US
The cheaper premium per month is NEVER cheaper in the long run
Insurance is about making money plain and simple .
We always figure on paying the monthly premium plus adding the max out of pocket which gets you 100% being paid

If you know a drug is not covered on your insurance then it is very hard to get it approved
Speciality drugs that are on the insurances approved list are hard to get approved but you have an uphill battle that can last up to 6 months or more with appeals while you are fighting .

You don't see your pcp every time
But you have to call your pcp for a referral typically
Prior to GI appts
The office meds extra time to send in the referral

Double check
Again insurance is about money

We have asked before if a procedure /test was covered
Were told yes it covered
But because we didn't ask specifically if the lab used for the test (only one in the country btw ) was out of network
They covered at out of network coverage which is 10% of the bill
Vs 80%

Loopholes
Be aware

 

[my little penguin]

We also spent close two months appealing to get a specialty drug approved that was listed
Ended up being denied complete on my insurance and after fighting finally got it approved on DH after multiple appeals and independent review

 

[andy58]

We also spent close two months appealing to get a specialty drug approved that was listed
Ended up being denied complete on my insurance and after fighting finally got it approved on DH after multiple appeals and independent review

what does DH mean? and thank you for taking the time to write to me!

 

[my little penguin]

Dh is darling husband
Ds darling son has Crohns -not me
So he is on two insurances

 

[Cross-stitch gal]

My parents have always had Kaiser and when I was born Kaiser was the one who I always had until I was into my 30's. When I was a child, my dad ended up with a mental illness and I watched my parents fight Kaiser all the time. They tried drug after drug on him and messed him up so bad that even now he doesn't sleep.

I ended up with a GI and every time I had anything regarding my IBD I had to talk to her. She was more like a saleswoman and was more into selling the big gun drugs (which I didn't need). Every time I flared she would put me on Prednisone. I'm 5ft and was always extremely underweight and she'd prescribe way too much drug for me (almost poisoned me at one point). She wouldn't even listen to my husband. And, there was no way to get an actual 2nd opinion because the 2nd opinion actually went through her anyway. Be careful with Kaiser because whoever you choose as a doctor will be your doctor for life.

In 2013 I changed from Kaiser to PPO and it was the best thing I ever did. In November I saw a different GI because mine wasn't available. And, while he listened to my doctor he also listened to my husband and I and made the decision himself on how I'm doing. I've also gone to more than one PCP and have done well there too. If it tells you anything, for the first time in my life I'm almost to a healthy weight.

I totally agree that cheap is not always better. Kaiser is more of a place if you don't have IBD. If you have PPO you can truly find a new doctor if you don't like the one you have.

 

[aypues]

I would get the PPO. And then plan on finding an IBD specialist in the area (not a regular GI doctor). there should be quite a few in the bay area. Kaiser is ok but can be a pain dealing with their limited system, and specialists in other areas can be difficult to get into.