Step Therapy

[u/InkGirl360]

I was diagnosed 2 years ago…I spent one full year agonizing what DMT to take. I landed on Kesimpta. I am the kind of person who gets sick from everything… even antibiotics. Kesimpta hasn’t made me sick at all! I feel like it’s a small miracle. I have been on the Bridge program and my one year is up. Uniform Medical has denied all of my appeals to stay on Kesimpta. They are demanding I do step therapy. I don’t think there was ever even a peer to peer, the pharmacologist has not been helpful… all letters are canned and not specific to me. I have EOE and cannot swallow pills and do not want to take copaxone when Kesimpta is working! A “fail” seems like it’s risking permanent damage and is insane to me. I’m so stressed out. Has anyone won this fight with Uniform Medical? Would a health insurance attorney help? Thanks :/

[u/VariationNo3725]

Have you seen if Novartis will extend/renew your time in the bridge program? I’ve heard that you can apply for an extension. Sending positive thoughts your way. 

[u/InkGirl360 → u/VariationNo3725]

Thank you- I will ask. I heard they have an extension for 2 months… but the first person I asked never heard of it. I will try again.

[u/aafreis]

If they are denying you the meds, you have the right to a peer-to-peer review.
As for anyone you speak to at the insurance, ask them for their name, license (NPI) number, and board specialty of the dr issuing the denial. Demand copies of all materials used to make the determination. Ask for proof that the dr issuing the denial is licensed to practice in your state.
You’ll also want to ask them what the aggregate rate at which similar treatments are denied vs approved for the specific doctor that is being used for peer-to-peer review.
Legally, they MUST provide in writing, all documents related to this entire fiasco.
They’ll try to tell you they don’t have to, but they do.

[u/criticalcreek]

I'll likely be facing something similar soon(hoping they finally give in though). The program runs out for me in February I think. My wicked insurance company has denied mine 4 times, and the denial letter showed that a regular MD, not even a neurologist, reviewed and said I needed to do step therapy, despite being high risk of developing more spinal cord lesions (that's where most of mine are). It's not worth the risk because a few more lesions there and I'm totally cooked. The also denied a lab claim recently to monitor my B-cell count, and I have no clue why yet. On top of that, my neuro may be out of network soon because they are in a contract dispute with the hospital. My state doesn't want to help protect the vulnerable and doesn't see healthcare as a human right so they don't have protection against step therapy, copay accumulator programs(another evil trick the insurance companies pull),and they never expanded Medicaid. When it rains it pours.

I wish I had better advice to give. My clinic can give samples and are partnered with the MS society to help people out, but I'm not sure how far that goes in terms of medication expenses. There are always clinical trials as well.

The most frustrating thing for me is that I heard some of those weaker DMTs are close/similar price of Kesimpta. I'm just assuming that they have a better negotiated price(maybe due to how long the others have been in the market)??? I have no clue, this is way past my knowledge so someone correct me if I'm wrong.

[u/InkGirl360 → u/criticalcreek]

I’m sorry you’re going through this too.

[u/criticalcreek → u/InkGirl360]

Insurance feels like such a scam sometimes. It's one of the worst aspects of having this disease so far imo and it's not even a symptom. It just adds an extra layer of stress to our plate 😞

[u/aafreis → u/criticalcreek]

If they are denying you the meds, you have the right to a peer-to-peer review.
As for anyone you speak to at the insurance, ask them for their name, license (NPI) number, and board specialty of the dr issuing the denial. Demand copies of all materials used to make the determination. Ask for proof that the dr issuing the denial is licensed to practice in your state.
You’ll also want to ask them what the aggregate rate at which similar treatments are denied vs approved for the specific doctor that is being used for peer-to-peer review.
Legally, they MUST provide in writing, all documents related to this entire fiasco.
They’ll try to tell you they don’t have to, but they do.

[u/Minimum-Ant5926]

Following

[u/worried_moon]

I’m sending you a quick DM!

[u/Big-Appointment541]

What is step therapy? I’m worried I’m going have same problem.

[u/The_Chaos_Pope → u/Big-Appointment541]

Basically, staring with the lowest efficacy medication possible and only moving up to the next step when you have new disease activity.