‘Tis the Season to be Screwed by Insurance

Ah, late December. A time of beautiful lights, giving, and the great health insurance scramble.

As co-founder of my company, I’m lucky enough to have a huge impact on choosing the health insurance we provide. One of the deciding factors for me is being able to get my Rheumatoid Arthritis drugs at a low co-pay. Through United Healthcare, it’s been $10 per month for methotrexate, $10 per month for folic acid, and $30 per month for Enbrel.

In other words, $50 a month for drugs. A reasonable-enough price to pay for my health. It is the number one reason we decided to keep our UHC plan for 2015.

So shock me, shock me, shock me (Any Empire Records fans? Read on, there’s a gif for you below.) when I get a letter saying that beginning January 1, 2015, Enbrel will be considered a “Tier 4” drug and will not be eligible for the Enbrel Assistance program. After some digging, I found out that this means it’s going up to $250 per month with no opportunity to enroll in any payment assistance programs Enbrel provides.

What? Merry Christmas to you too, United Healthcare.

Their advice? Try another drug.

That’s all good and fine. They’re willing to cover Humira or Cimzia, but I’m feeling pretty violated. I know violated may seem like a strong word for this situation, but that’s how it’s feeling. I’m being forced to put an unknown drug into my body because my healthcare has made an arbitrary change to their coverage. Enbrel is a known quantity for me. It’s effective in treating my RA, side effects are pretty minimal for me, and my body is used to it. Humira and Cimzia are not.

Not to mention, my rheumatologist claims that though the risk of switching is “probably pretty minimal”, there is a risk that I could lose the efficacy of Enbrel if I ever need it again. Joy!

So, have any of you RA folks made the change from Enbrel to Humira or Cimzia? How did it go? Are any of you on Humira or Cimzia? How did you like it?

Thanks for all your input and Happy Holidays to you all (in the non-grinchy, healthcare-trying-to-screw-you way, of course!)

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  1. #1 by Carla Kienast on December 16, 2014 - 4:24 pm

    Hi: I went from MTX to Humira to Simponi to Enbrel to Orencia to Cimzia to Xeljanz to Remicade and am now on my way to Kineret. Other than some initial injection site reactions, I’ve never had any side effects of the drugs except for Methotrexate where I had headaches and brain fog. I hate it when insurance companies practice medicine. And it’s really weird that they put an older drug like Enbrel on the list but approve newer drugs like Humira and Cimzia. All are TNF blockers so hopefully either one would be as effective for you as Enbrel. Good luck!

    • #2 by My RAD Life on December 16, 2014 - 6:56 pm

      Thanks Carla.

      Wow, you have tried them all! Do you switch because they lose their efficacy or is it due to insurance?

      It is just so frustrating and makes me nervous to switch treatments. 😦

      I’m typing up an appeal letter to United HC, but I’m doubting anything will come of it….

      Good luck with Kineret! I hope it is effective for you.

  1. Why Enbrel Support is Like Santa | My RAD Life

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