Changing meds

[BuckskinAsia]

My insurance recently denied paying for Besremi, which was working very well for me except for some problems with my eyes. Today I got my patient education for Jakafi. I’m overwhelmed right now. How is everyone doing on Jakafi?

[Wennn]

NCCN Guidelines have been updated to include BESREMi as a preferred therapeutic option.

Maybe you can appeal to your insurance again.

[hunter5582]

The emerging data on long-term impact of Jakafi is very promising. Some people do quite well on Jakafi and find it easier to tolerate than Besremi. Like all meds, we respond differently to the options.

Just because your insurance company denied the authorization from Besremi does not mean you cannot access it. This is a case where NO does not mean NO. There are additional levels of appeal available. You can file your own appeal, request a third-party review, involve the insurance commissioner from your state under certain circumstances. and more. Note that jakafi costs just as much as Besremi and unlike Besremi may have a requirement that you fail on hydroxyurea first. The insurance company would doubtless prefer you use a cheaper medication.

You have ample grounds for an appeal, including the fact that Besremi was just added to the NCCN guidelines as a first-line treatment for PV. The first step is to call your insurance company and request a copy of the plan rules (AKA Plan Guidelines) used to make this decision. They may not want to provide them, so be prepared to be very assertive. You will need to check to see if Besremi is on your plan's formulary. This affects how the appeal is written.

When I first sought authorization for Besremi shortly after it was FDA approved I was denied despite my doctor's best efforts. I was on a Medicare Part D Plan at the time. The denial said "There are no conditions under which this request would be approved under medicare Part D. We based this decision on the coverage criteria for: 2560 Medicare Part D Excluded Drugs - Plan Rules." This was the wrong answer. I called repeatedly requesting a copy of the Plan Rules cited. The insurance company never could find them and never provided them. this resulted in my filing a Medicare Grievance. I kept calling and refused to give up. As a result of many hours n the phone, I uncovered an error in how the original request was processed. Ultimately, I succeeded and got the Besremi authorized.

You do not have to do this on your own. You can contact PharmaEssentia Source for assistance. pharmaessentiasource.com/hcp/

You also have the choice to hire a patient advocate to assist you with your navigating the insurance company authorization and appeal process. Here are several organizations to find an advocate if you are interested.

nahac.com/

aphadvocates.org/

umbrahealthadvocacy.com/

Wishing you success in whatever treatment path you choose.