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Saturday, August 16, 2014

Through the Insurance Wormhole

5:56 AM Posted by Tiffany Taft , , ,
I went back and forth about writing this blog entry because it teeters on being too personal, as this is our practice blog and we, as therapists, need to maintain appropriate boundaries in life.  It's good for everyone involved.  I decided to write it with the intention to show that no matter one's status in this world, chronic illness is the great leveler of the playing field - specifically when it comes to health insurance.

Side note:  The title to this entry is borrowed from Morgan Freeman's television show Through the Wormhole, a show dedicated to "understanding the deepest mysteries of existence."  So you may want to read it in his voice for added effects.
I wrote a few days ago about being denied by my insurance company for a medication for Crohn's disease.  Not uncommon and certainly not something I haven't dealt with in the past.  The thing making this orders more complicated, and urgent, is my being scheduled for a repeat cesarean section on October 22nd.  Roughly 9 weeks from now.  My obstetrician emphasized at my last visit the importance of the disease being under control for things like, oh, wound healing.  

If I read the denial letter I received from my insurance company - which I should note isn't some mom and pop, rinky-dink company that you might expect to be more frugal, it states:

No clinical information has been received indicating you had inadequate response, intolerance, or contraindication to Humira.  

When I was on Cimzia before, I had different insurance.  The letter provides the coverage policy used, so I looked it up.  Apparently, if I didn't have an employer based plan but an "Individual and Family Benefits" plan Cimzia would be covered without the Humira stipulation.  
Huh?  Through the wormhole.

So I saw my gastroenterologist yesterday for an hour to discuss what my options were considering this denial of coverage.

Side note:  While I was the last patient of her day, if your doctor is running ridiculously behind schedule please consider (if you don't already, anyway) that he or she may be sitting with someone like me, that they're mandated by insurance to schedule in 15 minute blocks of time for return patients, and it's going to take more than that to sift through problems.  

In my discussion with my doctor, we talked about my options which included: 1) using Humira instead, 2) using prednisone for the short term, 3) doing nothing and waiting.  Let's start with #1.

Both Humira and Cimzia are in the same class of drugs which selectively suppress the immune system.  This same class of drugs have been a miracle for people living with not only IBD, but other autoimmune diseases.  They're also exorbitantly expensive, costing around $2,000 per month.  You may have seen commercials for Humira on television that include the person in the low, fast voice reading off potential side effects.  One of these is being more susceptible to opportunistic infections.  According to my doctor, Humira crosses the placenta much more than Cimzia (something about molecule sizes) so babies born to moms on Humira are pretty immune suppressed.  She said it's best not to expose my kid to any situations where infections are more abound, which includes no daycare for 6 months (I plan to return to work full time after 3), and delay all live vaccinations.  

Takeaway:  Your baby should live in a bubble for 6 months or risk catching some weird disease that he may not be able to fight off.  In my insurance company's decision process, this is a better idea than allowing me to take Cimzia and mitigate that risk.  Huh?  Through the wormhole.

To be fair, I'm guessing the department denying my medication has no clue that I'm pregnant even though I have several obstetrician claims with a billing code of pregnancy in the last 6 months in their system.  Going to guess those aren't linked up to make any type of deductive reasoning possible. 

On to #2:  Take prednisone.  Anyone who's ever taken prednisone can attest that it's a love/hate relationship.  The drug is older than I am and kicks ass and takes names for any inflammation going on in the body.  It's used widely for all sorts of problems and, in the past, was the go-to treatment for IBD. The problem with prednisone is its litany of side effects that start a couple of weeks into its use.  These include:  insomnia, weight gain due to increased appetite, water retention, acne, high blood pressure, bone loss, high blood sugar, irritability, depression, anxiety, psychosis (rare), moonface (swelling of the cheeks), and my personal favorite "buffalo hump" or a swelling of the skin on the back of the neck.  I've had 1 experience with long-term prednisone use, which was around 3 months, over 10 years ago and did have some side effects.  While prednisone is a category A or B drug for pregnancy, depending on who you ask, and is considered safe for the baby it comes with risks for the pregnancy itself:  high blood pressure which can lead to pre-eclampsia and high blood sugar which can lead to gestational diabetes.  Since prednisone is a drug as old as dirt, it costs about $10 a month for large quantities.

Takeaway:  Hey you might get severe complications for your pregnancy, but you can't beat the price on this drug so we'll cover this but not Cimzia.  Because, cha-ching!  Through the wormhole.

Side note:  My doctor put this whole denial thing into perspective.  There are about 1 million people in the US with Crohn's disease.  Let's say any one insurance carrier covers around 10% of them and assume all 100,000 of these patients are taking either Humira or Cimzia.  The simple act of delaying treatment for 30 days for each person results in net savings of $200 million for the company (100,000 x $2,000).  
"Excellent."
Finally, #3:  Do nothing.  Hope for the best.  Gamble that my insurance company will approve Cimzia in a relatively fast timeframe (it's been a week since the appeal).  I do have a wonderful gastroenterologist who is firm in her convictions about treatments and the like, but ultimately leaves the decision in my hands.  She does her best to make sure it's a very informed decision, and yesterday was no exception.  After digesting (heh) all the information we discussed over that 60 minutes, I decided doing nothing wasn't the best option.  Even though I'd be happiest not taking Cimzia or prednisone, because in my mind I'm not that bad off in terms of symptoms, I know it's stupid to opt for #3.

So, I start 40mg of prednisone today and hope the side effects are minimal.  At least I'll be super productive from the hypomania.  Oh, and insurance-company-that-shall-not-be-named and that whole $200 million savings?  You're welcome.