Skip to main content

Through the Insurance Wormhole

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).  
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.

Popular posts from this blog

The Long Shot

I don't even know where to begin as my head is still spinning with the news I received today.  So I'm just going to put it out into the ether:

Entyvio (vedolizumab), which I started for my Crohn's disease about 6 months ago, did what no other approach has:  cleared my eosinophilic esophagitis. 

But wait, isn't Entyvio a drug for inflammatory bowel disease?  Yes.

Is Eosinophilic Esophagitis a type of inflammatory bowel disease?  Nope.

Are IBD and EoE related at all?  As far as we know today, no.  There are very few overlapping cases.

So WTF happened?

Without getting into the biomechanics of a drug that's way over my pay grade in medical understanding, my gastroenterologist had a theory that the way Entyvio works would block the cascade of eosinophils (a part of your immune system, a type of white blood cell) through it's magical way of selectively keeping my immune system from attacking my digestive tract.

She was fucking right.

Since being diagnosed with EoE in ear…


I've been thinking a lot about how we live in an era of infinite access to infinite information (thanks, internet tubes!) yet we still fall into many of the well-established psychological laws, if we can call them that, of human behavior.  Don't worry, this isn't going to be some drawn out post on social psychology. Wikipedia is great for that.

I want to talk about bubbles.  Information bubbles, that is. And how each one of us lives in one to some extent, no matter how educated or enlightened we see ourselves to be. And even if we know we live in said bubble, it takes being shown information that directly conflicts with how you think things are, or should be, and the result is you feel kinda ew - the technical term for "ew" being cognitive dissonance.

I live in a bubble.

In my bubble is the world of academic medicine, academic health psychology, and a circle of psychologists dedicated to people living with chronic digestive illness.  I live in Chicago, a major me…

Everyone Can Fall Down the Rabbit Hole

A few months ago my 3 year old son uttered the words, "I hate you, mommy."  It was after I yelled at him for doing something wrong, which I've long forgotten what exactly the source of our exchange was. But I certainly can remember those words. I can hear them in my head if my brain decides, at random moments, to replay them.

My intellectual, clinical psychologist brain can explain this for days. He's 3, he doesn't know what he's saying, he learned the word hate somewhere else, presumably at preschool, as I discourage its free use in our house. He's using it to express his anger not his true feelings toward me because once he self-regulates (psychobabble for calms the F down) he tells me he loves me.  Blah blah blah.

Regardless of all that knowledge and shit I have from too much education, those words destroy me emotionally.  Maybe they hit me harder because of my profession because my head goes to all the subsequent pathology he'll surely go on to de…