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Choosing Meds - Insurance Issues?

Posted: Sat Jan 16, 2016 7:45 am
by littlestbabie
Hey! I was recently diagnosed with RRMS and given three different beginning drug choices. Tecfidera, Gilenya, and Copaxone. I was told that my insurance (Fidelis Medicaid) would fully cover the Copaxone, but that they don't currently cover either Gilenya or Tecfidera. However, the neuro resident I met with concerning the med information was very confident that although they would decline covering the medication a first time, so long as they re-submitted it a second time and made sure to note that I was needle-phobic (I'm not currently, but I used to be after dealing with finger-pricks daily for a blood sugar mutation and I'd prefer not to have to give myself shots) that they had a 95% chance of covering the medication. Now, I don't have the best track record with, y'know, having good luck. So I'm relatively concerned that Tecfidera won't be covered. It's definitely my first choice out of the three. I would rather not ever be put in a situation where I have to try Gilenya as the list of side effects is not only large but also very concerning. If I have to do Copaxone, well, then that's what I have to do. But I'd really rather give one of the new oral medications a try in the form of Copaxone. Has anyone had any luck with getting their Medicaid insurance to cover Tecfidera?

Re: Choosing Meds - Insurance Issues?

Posted: Sat Jan 16, 2016 11:40 pm
by ElliotB
Copaxone has many, many advantages over other medications.

While a daily injection sounds daunting, using the supplied Autoject makes the process simple and virtually painless (provided you get the injection depths correctly set for each site location).

Re: Choosing Meds - Insurance Issues?

Posted: Thu Jan 21, 2016 7:40 am
by Froggie

I understand the insurance conundrum you are in. I had to wait an additional four months in waiting for the government to put Tecfidera on their formulary. If you are concerned about insurance issues, I think Biogen-Idec who makes Tecfidera will work with you. You may also want to contact the MS Society, as they're very good about getting us the drugs we need.

I too hate needles, but I just sucked it up as something I had to do. I was on Copaxone for 9 months and eventually was told by an MS specialist that I was a non-optimal responder. I had severe hives at the injection sites and at least two relapses almost exactly four months apart. Not great odds for someone like myself. I was then on Rebif for almost 3 years, but then it too wasn't working that well. I then switched to Tecfidera as it was an oral drug and much more efficacious than the injectables on the market. It is also less expensive to manufacture. After being on Tecfidera for almost three years now, I've had no relapses and virtually no side effects. I feel better overall and less dopey, as I don't have to battle flu-like symptoms. No doubt choosing an MS drug is daunting, but ultimately it's your decision. Hope this helps!

Re: Choosing Meds - Insurance Issues?

Posted: Thu Jan 21, 2016 4:44 pm
by littlestbabie
thanks for the responses! i officially put in my request for tecfidera, and im feeling optimistic about it. my dr said it usually takes around a month to a month and a half for requests for coverage to be addressed/accepted, so hopefully my waiting period doesn't go beyond that time frame. I'm very anxious to get on medication & begin trying to discover which medicine will be best for me!

Re: Choosing Meds - Insurance Issues?

Posted: Wed Mar 30, 2016 12:29 pm
by littlestbabie
Just updating this thread - I finally got my appeal(s) accepted by my insurance! It took quite a while, and they denied my neurologist's request for the medication 3 times. It was a whole big thing, and I was constantly getting calls from from Biogen, the company who makes Tecfidera, as well as from my neurologist's office and my insurance. My insurance was pretty insistent that they didn't want to cover Tecfidera; they consistently attempted to push Copaxone on me instead, and they were quite pushy about it. (Not that I blame them, Copaxone is cheaper than Tec. Not by a lot, but certainly enough to be notable in the opinion of a large insurance company!) I had just recently contacted Biogen's financial aid branch, which was really helpful! They were beginning to work with me in order to help me financially so that I could begin the medication. If anyone else wants to try Tecfidera but is running into road blocks with their insurance, I would highly recommend talking to someone from Biogen's Financial Assistance department! I ended up not needing the financial assistance because my insurance finally approved my request and decided to cover the medication. All in all my first month's worth of medication came to roughly $5,500, and all I had to pay was a $3 co-pay! I'm super please with how it ended up. I just took my first pill today, one of the 120 mg starter pills. I've only taken my morning dose so far, and I didn't experience any side effects. I did what was recommended in LadyMac's advice thread: ate a big breakfast full of proteins and nutrients, and took an ibuprofen before I took the Tec. I didn't have any signs of flushing or gastrointestinal distress, which I'm very excited about, but we'll see if it holds up, haha!