khrios Posted February 1, 2005 Report Share Posted February 1, 2005 Hi,I have a friend who needs Enbrel approved by her HMO. She has debilitating arthritis and can no longer use celebrex and such because it affects her liver. Her doctor wants her to take Enbrel, but the insurance has denied it twice. She is supposed to write a letter of appeal explaining why she needs it. I figured some of you may know what to say to get some action from the insurance.Please help, she is in so much pain.Thanks,Ann Quote Link to comment Share on other sites More sharing options...
Miriam Poorman-Knox Posted February 1, 2005 Report Share Posted February 1, 2005 It seems to me that this is her doctors responsibility. Once a patient needs a medicine that is not on the formulary--the best and quickest route is your treating physician. Otherwise, I would contact the Arthritis Foundation and ask for their reaearch and info. I was on their board for 10 years and an educator for 5. They will have the info, but it still should be filtered through her treating physician Miriam Quote Link to comment Share on other sites More sharing options...
steph37822 Posted February 1, 2005 Report Share Posted February 1, 2005 oops Quote Link to comment Share on other sites More sharing options...
khrios Posted February 1, 2005 Author Report Share Posted February 1, 2005 The doctor stated that she has done what she could, and now it is up to my friend to deal with the insurance. I think docs get burned out of dealing with HMO's.Ann Quote Link to comment Share on other sites More sharing options...
Miriam Poorman-Knox Posted February 1, 2005 Report Share Posted February 1, 2005 The doctor stated that she has done what she could, and now it is up to my friend to deal with the insurance. I think docs get burned out of dealing with HMO's.Ann<{POST_SNAPBACK}> Let the doctor know that without her help this WON'T happen and that she should then prescribe another mediciane that will be appropriate. The doctoe might not LIKE to argue with the insurance co. over their formulary, but that is her job. Without someone on your side you will always lose. So the person who prescribed the med should fight for it. I do know how hard it is. My husband spends many nights fighting and calling ins. co. to get his patients what they NEED. That is part of the relationship. Remember WE PAY these professionals to care for us--often we have to educate them. My husband and I have been giving rounds to the residency programs inPittsburgh to educate them about POTS from both the patient and then professionally. This helps. Don't let the doc slide without an alternative. Miriam Quote Link to comment Share on other sites More sharing options...
MightyMouse Posted February 4, 2005 Report Share Posted February 4, 2005 Ann, the doctor, despite being burned out, has a duty of care to continue advocating for her patient to get the medication she needs. The doctor needs to point out that the items available through the preferred formulary are inappropriate and dangerous, and that Enbrel is appropriate.Nina Quote Link to comment Share on other sites More sharing options...
khrios Posted February 4, 2005 Author Report Share Posted February 4, 2005 My friend and I wrote a letter, and the doctor prepared a packet of information for the appeals panel. Hopefully, it will work.Ann Quote Link to comment Share on other sites More sharing options...
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