Friday, November 6th, 2014 my insurance was "unable to approve [my] physician's request for coverage of CIMZIA. The request did not meet the conditions necessary for coverage for the following reason(s)."
"The request for coverage for Cimzia is denied. This decision is based on health plan criteria for Cimzia. This medicine is covered if you meet the following criteria: You have positive clinical response to Cimzia therapy. The information sent in does not show you meet these criteria."
I quoted the above from a letter I received from my insurance. The letter also included a page of information and guidelines about the appeals process.
Sunday, November 9th, 2014, I reached out to a Team Challenge mentor, Tom, for advice on this situation. Tom let me speak to his badass wife, Liz, because she's the one that has handled a few of these situations for their son with Crohn's disease. Before speaking with Liz I felt hopeless and lost because I really didn't know what I should do. Liz advised me to contact insurance first and get a specific answer as to why they decided to deny coverage. Liz also counselled me to inquire about what I can do to regain coverage without having to go through the appeals process. She told me to stand firm and not to take no for an answer. She then instructed me to call her back if my call to insurance doesn't find a solution. By the end of our conversation, Liz had calmed my nerves about the situation. It was nice to know that I have someone on my team with experience coaching me to win this enduring struggle with insurance.
Today, November 10th, 2014, I contacted insurance. It took five minutes convincing the automated robot to let me speak to a human before I actually got a human on the line. The human's name was Craig. The following is paraphrased after Craig confirmed who I was and my insurance plan:
Me: I'm calling to find out why coverge of my Cimzia medication was denied.
Craig: It looks like we won't cover the brand name Cimzia, but we will cover the generic brand Certolizumab Pegol.
Me: Cimzia does not have a generic brand. I have been taking Cimzia for the past two years, which you guys have covered for the past two years. Why the sudden change in coverage?
In the meantime I'm googling "Certolizmab Pegol" to figure out where he is getting this name from because I know for a fact that there is no generic brand of Cimzia and the first hit on Google takes me to http://www.cimzia.com/. I conclude that Certolizmab Pegol is the clinical or scientific name for the medication Cimzia, which my gasto nurse confirms later in the day.
Craig: We have not ever covered Cimzia. We have covered the generic Certolizumab Pegol.
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| A photo of my Cimzia medication they have been covering for two years. You can see in parenthesis under Cimzia the Certolizumab Pegol name. |
Me: Certolizumab Pegol is Cimzia.
Craig: No, we will not cover Cimzia.
At this point you can imagine my confusion.
Me: Okay, so do I get approved for this so called generic?
Craig: Have your doctor send another prior authorization for the generic or have your doctor contact us at an 1-800 #.
Me: So, if my doctor sends you guys a prior authorization for Certolizumab Pegol, it will be approved?
Craig: Yes.
Me: Okay, so you won't approve Cimzia, but you'll approve Certolizumab Pegol, which is the same thing as Cimzia?
Craig: It's the generic brand of Cimzia.
This ended my conversation with Craig, the dumb human voice of the insurance company.
I followed my call with Craig with a call to my gastro nurse, Osmarie. She explained that the prior authorization paper work she got to fill out had check boxes with Humira, Cimzia, or Remicade (these medications do not have a generic form. They are too new and too complex). It just prompted her to check a box, so she checked the Cimzia box. There wasn't even a space on the paperwork for her to write in Certolizumab Pegol, so she called the 1-800 # I gave her. Within the hour she got the confirmation that insurance approved Certolizumab Pegol. Osmarie told me that is just the clinical name for Cimzia and that there is no generic brand for Cimzia.
This whole ordeal has left me dumbfounded. Insurance makes me cry, shake my head, and smile at their stupidity. My medication has been approved! I call it Cimzia. Insurance calls it Certolizumab Pegol. Just don't tell them that Certolizumab Pegol is Cimzia, or they might decide not to cover it. It will be delivered just in time for my scheduled November injections.
