Thinking of suing Empire Blue Cross

[AndrewEsq]

Hi everyone,

Here's what's happening in a nutshell: I've had Crohn's since October 2012 and have been on Pentasa and Entocort. I was on GHI since December 2013, but then switched to Empire under the New York State of Health Marketplace. It is the platinum plan and it is $550 a month. I live in New York and I'm single. When I signed up, the plan said it covered prescription, generic and preferred drugs. It was the same as GHI.

Anyway, Empire refuses to pay for Pentasa. They claim it is "not a necessary drug", among other things. They also question why my doctor put me on Pentasa first and didn't try other medications. My gastro has sent over a prescription to Express Scripts, including an authorization, but Express Scripts refuses to send it because my health insurance won't cover it. So now I ran out of Pentasa and using samples from my gastro's office.

The gastro is going to speak with them but my samples run out by the end of the week. I need this medication! Even though going to court seems very ridiculous, I am running out of patience with this health insurance company; this is Empire and not some small insurance company that does not carry these drugs. And it is not like I am requesting Advil; this is a very serious and chronic illness. Empire claims Pentasa is not on their list of formularies, but there's no other medication I am aware of that is the general medication besides Pentasa!

Is anyone else struggling to get medication because their insurance company won't pay for it? My dad never had issues, but this has been a long battle for me ever since I was diagnosed, even when I was under GHI and paid $580 a month for full coverage.

 

[2thFairy]

Are they objecting to Pentasa in particular or mesalamine drugs as a whole? There are other mesalamine drugs like Pentasa that may act just as well, if not better, for you. There is Apriso, Asacol HD, Delzicol, and Lialda.

I do think it is odd that they would object to paying for Pentasa, though.

 

[2thFairy]

Also odd is that they are questioning why your doctor has you on Pentasa first. Pentasa usually is the first drug prescribed for Crohn's/UC and then quickly eliminated as not being effective.

I suppose they will push for Imuran or prednisone, since those are both SO much cheaper for the insurance company, yet more dangerous to you. That really sucks!!!

 

[DustyKat]

I am not is the US so don’t know the why and wherefores of the insurance system and must admit do not understand how insurance companies can override a specialists prescribed treatment plan.

Your GI has started out on a mild route as he obviously feels that this is an appropriate path for you at this point. You are on a steroid (Entocort) and first level drug (Pentasa). From that I assume you disease either in the ileum only or the ileum and ascending colon as this would be the best fit for this combination. If you do have Crohn’s in the Terminal Ileum or Ileocolitis then your choices of 5ASA’s will be limited to Pentasa or Salofalk.

As 2th Fairy has said, ironically enough the next step to immunosuppressives and a change away from Entocort to the more systemic Prednisone is a cheaper option for the insurance company. Now, what was that they said in their spiel about looking after you? :voodoo:

Dusty. xxx

 

[DustyKat]

We have universal health care in Australia and our medications are subsidised under a scheme called the PBS (Pharmaceutical Benefits Scheme) So a drug that has been approved by the PBS is charged at a full script price of $36.90. You never pay more than that. If a drug is cheaper than $36.90 then you pay that price and if you have a healthcare card or you are a pensioner you pay $6.00

I don’t know the cost comparison between Entocort and Prednisone but I can tell you what it is between Pentasa (5ASA) and Imuran (this is the next class of drug up from the 5ASA’s, it is an immunosuppressant) as my son takes both and they list the full price on the label. I don’t know what the insurance company’s motives are but if they are cost driven this would be why:

Pentasa 1g Tablet (120 tabs per box) - Full cost $330.90 AUD

Imuran 50mg Tablet (100 tabs per box) - Full cost $44.25 AUD

Dusty.

 

[Droopy Drawers]

• Pentasa: Shire Cares Program. Must call for more details. Information:
http://www.shire.com/shireplc/en/con...ientassistance

 

[AndrewEsq]

Are they objecting to Pentasa in particular or mesalamine drugs as a whole? There are other mesalamine drugs like Pentasa that may act just as well, if not better, for you. There is Apriso, Asacol HD, Delzicol, and Lialda.

I do think it is odd that they would object to paying for Pentasa, though.

Can you describe the differences, and side effects, of these drugs you listed? None of the gastro's I have visited ever recommended any of these drugs to me. With pentasa and entocort, I do not have flare-ups, but I still do have abdominal pains. Not bad ones...just irritating, and the pains occur daily.

Since I have "mild to moderate crohn's", all have recommended I be put on Pentasa, stepped up with Entocort and then leveled off on the Entocort. Since my symptoms return when I level off, just staying on pentasa is not an option, so the gastro I have wants to put me on Humira (the health insurance company has taken a similar stance with Humira--they rejected it at first since an old gastro I saw up until two weeks ago was not on the health insurance plan--but then they retracted the letter and said, since I am seeing this new gastro, there shouldn't be a problem.) They still rejected pentasa when I spoke to the insurance company yesterday. I am ultimately not sure now if they will approve or reject the humira...I will find out in a week or two when the doctor calls them up. I told the doctor's office litigation might have to be my next step. What a sad, sorry state of affairs when you have to go to COURT to protect your health...and I am a lawyer!! :ybatty:

They rejected pentasa because of costs I am sure, because it is not in the "formulary." But it angers me that they are trying to get between my doctor and me. If my gastro says "pentasa", then it is pentasa. If he says "humira", then it is "humira." That is what angers me.

 

[DustyKat]

The Mesalamine medications (5ASA’s) are the same base medication but the different types are engineered to be released in different parts of the bowel...

Pentasa and Apriso - can release 5-ASA directly to the small intestine and colon.

Delzicol, Asacol HD and Lialda - The lower part of the small intestine and the colon.

Dipentum, Colazal and Sulfasalazine - The colon only.

…so as you can see they are very much disease location specific.