My Tecfidera Prescription Isn't Covered By My Insurance

I am a little sad at the fact that my insurance doesn't cover my prescription. I know that the medicine may not have worked but I was just ready to begin the process of finding out what does work. I called my Neurologist's office and was told that the appeal process was taking place right now. They have to justify why Tecfidera opposed to any other medicines and it can take 4 to 6 weeks. I am ready for my current symptoms to stop but I will have to wait longer now.

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33 Replies

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  • Hi Taylorsmom

    I think that's pretty typical

    Hang in there 👍

  • I'm sorry, Taylorsmom. I hope your ins. co. accepts your doctor's justification and the Texfidera is approved. As erash said, hang in there. 💕

  • Thank Tutu , I'm just waiting and staying prayerful.

  • Sorry about that. Hope it goes fast.

  • I do too Morllyn

  • If insurance companies would realize that the stress on us trying to jump through their hoops, costs them more in the long run. Feeling your pain. Hope you feel better soon.

  • Thank you Iona60

  • Hang in there. Keep pushing

  • Taylorsmom anyway you can call your insurance and bug them a bit yourself? Call your pharmacist and have them call your insurance company also. Sometimes, the more noise you make can help.

    And call

    mymsaa.org

    (800) 532-7667 ext. 154

    And let them help you also☺

    Hang in there

    Jes🌠

  • Thank you Jesmcd2 , I will do all of these things. They did write me a letter to explain why they didn't cover it. They suggested other medications first before starting Tecfidera of the suggestions, only about 2 were MS medications. I feel like they're looking at the cost and not what it takes to handle MS.

  • Call the drug company their will help you out

  • When my Rx was initially denied, I felt as though that was it, that I couldn't do much about it. I made many phone calls, the first one being the insurance company. I was told they were "missing diagnostic information." I asked what more they could need, since the MRI was clearly positive with clinical symptoms to match. I called my neurologist, who said they would look into it further. After a couple more phone calls, I got the approval. I don't know if it's true, but have heard ins. companies routinely deny coverage initially, but a little pressure and clarification can be all it takes.

    Don't give up yet! We will be praying for a quick resolution!

  • Thank you greaterexp , I really appreciate the prayers! I received a letter suggesting other medications opposed to the Tecfidera. I think that it has something to do with the cost at $60,000 a year. Of the medications that they suggested, I think only 2 of them were for MS, I didn't research them, I just know they weren't the 14 that are available for MS patients. My neurologist is going to appeal the denial, I was told it would take about 4 to 6 weeks before I hear anything further.

  • Call Biogen & see if they still have a Patient Assist Program, then maybe the MSAA or the MSocirty. They may have ideas for u to chase up. Maybe your near & ask them wait they suggest, as waiting is NOT YOUR best option. Looks like u r going to have to push HARD on this one. Rother meds an option for you?

    Remember it is YOUR ms, u r the one who has to give a little shove to get what u want & need.

    Royce

  • Taylorsmom When I was first dx the Rebif I was prescribed was not covered with my ins. I went through appeals and the company's assistance program. I ended up contacting one of our US Senator's offices. They apparently have a staff member that works on ins. claims. My case was not resolved when I had to stop the Rebif due to complications, and by then they had determined I had PPMS and there was no treatment. So politics is another avenue you could pursue if it comes to that. I am wondering if I am going to face something similar if the new Ocrelizumab is approved.

  • bavery207 l hope you won't! Will be thinking of!☺🌠 Good Luck!

  • I hope that you don't have to go through all of that again bavery207 . I think that I'm going to start with company first, a lot of people have been suggesting that then I'll go from there.

  • Find out if the drug company has options to help?

  • Try contacting Biogen (manufacturer) they have a copay assistance program, your doctor can get the insurance company to make an exception for the medicine, .I have been on Tecfidera,I can only tolerate a 120 mg dose but my MRI is still showing positive results

    I hope this helps you if you have any questions feel free to ask

  • Hi Birdymom3 , I plan on calling them Monday morning. How long have you been on Tecfidera? Do you have any of the side effects?

  • Hi @taylorsmom, It sounds like you will need to let the appeal process play out, but definitely look into a Patient Assistance Program through the manufacturer, as others have suggested. I have been getting Ampyra that way for a while now. I need to reapply every year but so far it has worked out well.

  • @Taylorsmom, I am 73, on Medicare and AARP ins. When prescribed Tecfidera my Dr's office applied for assistance from Biogen. Biogen responded and found free coverage for 1 yr, since we are within the financial parameters. Now, that has ended, and am being covered by a grant which will cover my out of pocket expenses for insurance, until maximum is reached, then insurance will pay full amount. There are apparently many ways to obtain assistance. Don't stop until you have followed all potential avenues of assistance. Some states also have plans to help with drug expenses. Make calls and find out, because the way I read the info, being under Medicare and ins. I should not have received the assistance. Good luck.

  • Thank you 4fishylady , I will look into all of these things.

  • Taylorsmom, it's Fancy1959. Why hasn't your neurologist contacted the drug manufacturer to see if you can qualify for zero co-pay assistance from the drug manufacturer? When I took tecfidera I qualified for this gyro copay assistance. I'm amazed your neurologist has check on that for you. Stand up and request it be checked immediately. Biogen does do co-pay assistance for patients who need it.

  • Hi Fancy1959 , I plan on making calls on Monday. I think I recall my neurologist telling me about the co-pay assistance but I think they need to exhaust all requests first. That will be one of my questions when I call on Monday.

  • Good luck they are usually very helpful and caring and understanding

  • Thank you Birdymom3 !

  • My neurologist filled out the paperwork for the manufacturer zero co-pay program and sent it to them the very same visit he and I decided to give Tecfidera a try.

  • yes, Taylorsmom, mine was also done very propmtly by my Neurologist's office. Unfortunately not all neurologist offices play by game book, so to say.😞

  • I didn't read all of the responses, but definitely recommend contacting the drug manufacturer, they often offer assistance. Doesn't cost you anything to ask.. Hope you get settled on meds that help.

  • Tecfidera does have copay assistance.....that basically pays your entire copay (even if you are on a high deductible plan), so basically they pay for the entire cost. I've been on it for three years and I've never paid for any of it.

  • Hi mhepler531 . Thank you, I've been hearing about the assistance, I can vaguely recall my neurologist telling me about it as well. I think that it has to go through the whole denial process first before I can get the assistance. How are you doing on the Tecfidera?

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