After Five Months of Fighting....
After five long months of fighting and paying 1500.00 per month for medication out of our pocket, Anthem Blue Cross and Blue Shield gave up and is paying for Wes' Humira.
It only took hours upon hours of time by Wes' fabulous Rheumatologist, Dr. Nathan Wei, as well as my legal work and persistence, as well as the help from the Virginia Insurance Commission's Office of the Ombudsman. It didn't matter to Anthem that the law in Virginia requires that they pay for drugs they determine "experimental" if they are FDA approved AND there is evidence in the literature that they are effective for the specific disease. Then, of course, at the 11th hour, after submitting letters and articles and studies and paperwork and waiting for the ruling, they gave up so that there wouldn't be a precedent that others could use to get the medications they need.
Humira is FDA approved for Rheumatoid Arthritis and in the pipeline for approval for Psoriatic Arthritis. There is significant research that proves its efficacy for Psoriatic Arthritis including Phase III clinical studies and approval by the EU. It is the only drug that Wes can use, given the previous one gave him neurological side effects. But Anthem didn't care about any of that. They denied the coverage, despite everyone's explanations, and the fact that without the drug, the disease gets worse. None of that was important to Anthem, and the only way they would even listen was after we found a way to pay for the drug for 4 months...$6000.00 worth, AND fight through the annoyance before they would finally give in.
I can only wonder what happens to people who don't have their doctors behind them and happen to have a lawyer for a wife...
If any Rheumatologists in Virginia want a copy of the briefs we filed if Anthem has turned down THEIR Psoriatic Arthritis patients for Humira, drop an email to ooblick at ego dot org.