I’ve been on Simponi for about a year for PIC (after being on Humira and developing antibodies to that). The Simponi is working so far, but my new Aetna medicare advantage insurance plan is denying any refills, after 3 appeals. They say it’s “off label” which is true, but FDA has not approved anything else that works for me. So now I have no medication. Any advice on how to deal with this? Simponi is so expensive out of pocket. Hire a lawyer? Switching out of Medicare Advantage to a traditional Part D plan? Thank you for any advice you can provide.
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Thank you for your reply. We are trying the grievance route by appealing to a Medicare administrative law judge. My doctor’s office has been very helpful. Will update when I get a decision. Yes, tried the patient assistance option with Janssen but, after a long runaround, they said I don’t qualify bec they only assist people with on label conditions.
Paying out of pocket for Simponi would cost about $6000-$7500 per month. So, unless the judge rules in my favor, I don’t know what I’ll do. There is no “on label” option that is effective for me.
Any medicare plan has the right not to cover due to off label use. You may have a better option with a part D since some will cover off label, but this is not a guarantee as again it is a medicare plan. I assume you tried a patient grievance? A lawyer may help, but again no guarantee. Did you try free drug option from company?