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  • kmiriam
    Hi everyone,

    I have been having a VERY difficult time getting Aetna to approve my tecfidera prescription--specifically, they are denying it bc they want me to take some other drugs first and 'prove' i suffer on them. I was diagnosed a few months ago and am very frustrated that they are trying to force me to take injections and meds with worse potential side effects.

    I am wondering if anyone has any experience or knowledge or just a story to share about Aetna and Tecfidera. I have file the appeals, been denied, etc and am continuing to follow up, but sounds like I am going to have to try one of the injections first and then cross my fingers they let me take tecfidera.  I am wondering if I should get a laywer?

    As you can imagine, it's very stressfult o have to be dealing with this instead of focusing on learnign to live wiht my new diagnosis/taking care of myself, so I appreciate all the insight in advance.

    -Miriam
  • susan_c_b
    My experience is not with the same insurance or drug as you.  But the overall scenario was exactly the same:  Anthem Blue Cross, denying coverage of Gilenya, insisting I stay on an injection for 6 months.  (I tried copaxone for two months and it was awful.)  The doctor followed up with appeals, but they were still denied.  

    It's incredibly frustrating when number-crunchers in an insurance company trump a doctor's  expertise, but unfortunately, that happens a lot.  It's a money thing, I'm sure.

    I know my answer doesn't solve the problem, but at least you know you are not alone!
  • nursep
    I would try and think of reasons why Tecfidera is the better option for you and list them all and have your dr refax an appeal. For example any prior health conditions, fear of needles, etc. Oh! and add that according to some studies: The injectables vary from 28-33% less relapses and Tecfidera runs at 48%. (I don't know if those are the exact numbers and it always varies on the study) and ask why you would be denied the most effective treatment according to "such and such study."
     If you have to do the injectables, then I suggest you journal with every injection and list every side effect, symptom, experience, you encounter and fax to insurance monthly with a request for coverage of Tecfidera. Persistance can pay off.
    Sorry about your new diagnosis! Mine was over a year ago and I am still learning how to live with my MS and try to get along with it. I don't like my MS but can't make it go away so, must learn to keep the peace between me and MS and just deal. LOL
     
  • nursep
    I would try and think of reasons why Tecfidera is the better option for you and list them all and have your dr refax an appeal. For example any prior health conditions, fear of needles, etc. Oh! and add that according to some studies: The injectables vary from 28-33% less relapses and Tecfidera runs at 48%. (I don't know if those are the exact numbers and it always varies on the study) and ask why you would be denied the most effective treatment according to "such and such study."
     If you have to do the injectables, then I suggest you journal with every injection and list every side effect, symptom, experience, you encounter and fax to insurance monthly with a request for coverage of Tecfidera. Persistance can pay off.
    Sorry about your new diagnosis! Mine was over a year ago and I am still learning how to live with my MS and try to get along with it. I don't like my MS but can't make it go away so, must learn to keep the peace between me and MS and just deal. LOL
     
  • karenjanel
    I know that I am a bit late as I was just diagnosed yesterday and told that I would be put on Tecfidera too.  I also have Aetna and Tecfidera is not on their preferred drug list.  I was quoted $250 per month as my co-pay which is way too much.  Tecfidera has a $10 co pay plan for anyone regardless of income as long as they do not have government provided insurance like Medicaide.   It is advertised on their website/  You may want to check it out.  Hope this helps.

    Above is my original note from the end of November and here is my update:

    Today is 12/30/13 and I have been diagnosed for over 39 days and no treatment has been approved by Aetna.  Just like the OP they want me to try Copaxone, Rebif, of Avonex for a month with me having a bad reaction prior to approving Tecfidera.  My Dr. is hopefully going to contact them tomorrow to do a peer to peer to go over why he recommends Tecfidera as my first drug for treatment.  Not to put my business out there but I pay over $600 a month from my pay check in health insurance and the first time I have a life altering event, Aetna wants to drag their feet. Ugh! Now I see the issues that people talk about when they complain about their insurance companies.  I still may be able to be approved with the Tecfidera $10 co-pay but I have to wait for the peer to peer to be completed.

    Wish me luck!
  • new2me
    I too was told I would be put on Tecfidera and I'm not sure how long it takes to get it but I don't have Aetna insurance. I'm planning on contacting my insurance to see what my co pay will be since I'm not really sure.  I also want to find out more info on the Tecfidera site regarding the $10 co pays so I guess I better check into that so I know before hand.  Best of luck
  • Ang87
    Hi there! It really does seem to be a hassle to get started on this med. I have UHC and they denied me for Tecfidera as well. My neuro's office jumped threw alot of hoops and finally got me started on it. I've been taking it for about 6 months. So far so good, and no relapse! Keep your fingers crossed, my last relapse was in April of last year and it was a doocey. Just try and stay patient. I hate how insurance companies have so much say-so. UHC wanted me to try other meds "injections" before hand which is why I was orginally denied. What is stupid is if they would have okayed me for it, I would have to pay $50 a month but since we had to go a different route I only pay $10. Ofcourse, this is good for me I save $ but seriously I really dislike insurance companies. It doesn't help I have to deal with them where I work. Hang in there, this is a good med! Word of advise when you do start to take it: make sure to eat. My stomach gets really upset if I don't. Take care!
  • cyndihart12

    don't know if you got this worked out and maybe my situation is different because I'm on Medicare but

    1). My neuro did not put me on a DMD until tecfidera became available (about 6 months after my dx) because it's the only DMD with no risk of brain infection and I'm at high risk of getting it.

    2).  I was partnered with an advocate at Biogen Idec to get me funding/insurance to cover the cost of the medication (evidently a one month supply cost approx. $6000).  She found me OptimRX.  This is completely separate from my Humana, I pay no premium and it only covers my Tecfidera.  Of course, the Tecfidera comes to me directly from the Walgreens Specialty Pharmacy.

    concerning the drug itself.  It upset my stomach for the first month and the third month but otherwise no adverse reaction.  I haven't seen any benefits.  I still have a lot of flares they just don't last as long as they used to.  Average one week instead of two.

  • landruss

    I have been on Tecfidera for 6 months.  I was on Rebif for 4 years.  The doctor said you won't know it's working.  You'll only know if it's not working.  I have Blue Cross and a $30 copay.  All of my meds combined are over $100.  The insurance always wants more documentation before they approve an insurance so don't panic yet.  I didn't really have been side-effects from Rebif it just seemed logical to switch to a better med when it came out.  You'll be able to hang on if you have to.  Just keep good documentation so that you can mound a good argument for a change in meds. 

     

  • jkriegler85

    The same exact thing has happened to me.  Aetna declined it over and over.. We battled with them for almost three months.  Then one day Tecfidera called me and told me that they were going to give me a year free of the drug.  So after that year is up the insurance can not make you switch your medication you are taking for your M.S.  I can give you phone numbers to call if you would like.  I know it is very agravating.  Aetna would not even pay for my steriods when i was having a relapse... 

  • jkriegler85

    The same exact thing has happened to me.  Aetna declined it over and over.. We battled with them for almost three months.  Then one day Tecfidera called me and told me that they were going to give me a year free of the drug.  So after that year is up the insurance can not make you switch your medication you are taking for your M.S.  I can give you phone numbers to call if you would like.  I know it is very agravating.  Aetna would not even pay for my steriods when i was having a relapse... 

  • emily0507

    <p> Hi Miriam,</p> <p> I also have Aetna and received the same nonsense from them on approving my Rx. Since I&#39;m newly diagnosed, they wanted me to try Rebif before starting on Tecfidera. Once I received the call from Aetna telling me this, I received another call from BioGen, who makes Tecfidera, telling me that they would cover my Tecfidera for a year FOR FREE. Try giving BioGen a call - it&#39;s worth a try!!&nbsp;</p> <p> &nbsp;</p> <p> Good Luck!</p> <p> Emily</p>

  • admorrison2013

    I just started Tecfidera a week ago. But you should really call and talk to them. They've been extremely helpful to me with everything. Their number is 1-800-456-2255.

    You should really give them a call.

  • amyperl

    Hi Miriam,

    I am, right now, in the middle of waiting for my "approval" so I can begin my Tecfidera! It's been taking a couple of weeks now, and I"m still waiting. In the meantime, I am continuing to do my daily Copaxone injections. I have been on Copaxone since Feb. 2012 and I have virtually no side effects. The injection site hurts for a few minutes, but then it goes away. I do have a small itchy spot there the next day, but it's no biggie. In all honesty I'd rather this side effect than the possible sided effects from Tecfidera that may happen! Although I'm sure it'll all be fine. I've heard if you stick with taking the pills with a fat/foods, and do the baby aspirin thing before hand too, it's generally ok.

    Good luck with Aetna! I'm going to make a few phone calls on Monday to see if I'm also in the loop you are...I hope not.

    Best, Amy

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