Re: Reauthorization by Athem-CA

[Guest guest]

I have Anthem BC of CA and have not had to fill out any paperwork . I have

been getting Xolair for over 2 years now and have never had a review. It

might be how your employer (or those who offer the plan) have it set.

B.

From: [mailto: ] On

Behalf Of billybaroo1958

Sent: Saturday, December 27, 2008 11:55 AM

Subject: [ ] Reauthorization by Athem-CA

I don't imagine everyone fits the criteria of the question, but I am up for

an annual review if

whether I should be allowed to stay on Xolair. I have been on one year, and

my assumption is

that it is policy for Anthem CA to have the patient re-submit a new prior

authorization every

6-12 months. I remember vaguely a conversation here about someone who

improved

clinically on Xolair and was taken off because his/hers numbers went outside

the criteria

range to stay on the drug. Stupid we can all agree, but despite my IgE

(before Xolair 355 and

after 525) still within the criteria, my positive tests for aeroallergens

while on Xolair, my lung

functions have improved enough (>80% for FEV1) to say that I don't require

the drug. Of

course the idiotic logic is that it was supposed to help my lung functions.

However, my

doctor has told me that Anthem might want to see me fail again in order to

put me back on

it. Clearly I know this is all about money, but I feel like a lab rat.

Just for anyone's edification, if lung functions improve because of Xolair,

that should be a

logical outcome and not a reason for removal from the drug. However, if IgE

numbers

plummet AND positive tests for aeroallergens are negative while on Xolair,

then that might

justify a period of time off the drug. I will let you know what happens, but

I have begun to

prepare to have to fight to stay on the drug because I did so well on it.

Crazy

[Guest guest]

I'm sorry to hear about this. I just went through something similar,

but I suspect it was because the BCBS pharmacy approval team is

contracted out to Medco, and someone at MEdco goofed. Regardless, I

started deterioriating immediately when I was waiting for my appeal

to be heard. SO, I started faxing the appeals coordinator for my case

about how I was doing, how within a couple of weeks I was on pred and

antibiotics, how I " m not supposed to take pred due to years of taking

it and now having osteoporosis and high BP as a result. In short, I

made sure I was the squeaky wheel.

I ALSO, called my specialty pharmacy and told them. They have a

couple of nurses specifically assigned to appeals and reauthorization

processes to advocate on behalf of their patients (and, of course,

their bottom line). This was actually helpful. As a result of my

whining, initially I got a one month authorization approved until the

appeal could be finalized. It was right before Thanksgiving, and the

appeals nurse at the specialty pharmacy worked with me to expedite

THEIR processing of the one month authorization so that I could get a

last minute overnight shipment in time to get a round of Xolair shots

before the holiday started, thus allowing me to start tapering off

pred five days earlier than I would have.

I ALSO called my doctor's office every day asking if they'd had any

contact with my insurance folks to make sure that they were doing

everything that was required of them in a TIMELY manner.

Remember, EVERY TIME ONE OF US fights for him or herself, that ONE

fights for ALL OF US.

Good luck, and let us know what happens.

Addy

Group co-owner

--- In , " billybaroo1958 " <cajjz109@...>

wrote:

>

> I don't imagine everyone fits the criteria of the question, but I

am up for an annual review if

> whether I should be allowed to stay on Xolair. I have been on one

year, and my assumption is

> that it is policy for Anthem CA to have the patient re-submit a new

prior authorization every

> 6-12 months. I remember vaguely a conversation here about someone

who improved

> clinically on Xolair and was taken off because his/hers numbers

went outside the criteria

> range to stay on the drug. Stupid we can all agree, but despite my

IgE (before Xolair 355 and

> after 525) still within the criteria, my positive tests for

aeroallergens while on Xolair, my lung

> functions have improved enough (>80% for FEV1) to say that I don't

require the drug. Of

> course the idiotic logic is that it was supposed to help my lung

functions. However, my

> doctor has told me that Anthem might want to see me fail again in

order to put me back on

> it. Clearly I know this is all about money, but I feel like a lab

rat.

>

> Just for anyone's edification, if lung functions improve because

of Xolair, that should be a

> logical outcome and not a reason for removal from the drug.

However, if IgE numbers

> plummet AND positive tests for aeroallergens are negative while on

Xolair, then that might

> justify a period of time off the drug. I will let you know what

happens, but I have begun to

> prepare to have to fight to stay on the drug because I did so well

on it. Crazy

>

[Guest guest]

I have to re-auth too because my insurance has changed to another BCBS

policy with Medco doing all the presctiptions.

I was on this plan year before last so I don't expect any problems.

My allergist has 15 xolair patients and has one nurse that handles all

the auth's paperwork and administers the shots.

Doug

[Guest guest]

Well it has nothing to do with my employer. I talked to Wellpoint who are the

pharmacy

plan for Anthem and my insurance, so I likely has to with the former. When

Wellpoint

authorized Xolair last year they only wrote the authorization for one calendar

year. I got

the sense from the people at Wellpoint that this how they write the approval for

Xolair for

everyone. The silliness is that theoretically the doctor can say one still needs

to take

Xolair, document this and still be turned down by the review doctor at Wellpoint

by saying

" we don't think the drug is a medical necessity " . Ideally, Xolair is intended to

improve lung

function and/or allergic reactions and alter Ige levels. So, the reviewer can

say, " the new

lung functions results don't fit the criteria to take the drug " , because of

course I improved

on the drug. My doctor has already prepared me for the possibility that

Wellpoint will want

to see me fail off it, in order to put me back on it. Personally, I think it is

just that they

don't want to pay for the drug.

>

> I have Anthem BC of CA and have not had to fill out any paperwork . I have

> been getting Xolair for over 2 years now and have never had a review. It

> might be how your employer (or those who offer the plan) have it set.

>

>

>

> B.

>

>

>

> From: [mailto: ] On

> Behalf Of billybaroo1958

> Sent: Saturday, December 27, 2008 11:55 AM

>

> Subject: [ ] Reauthorization by Athem-CA

>

>

>

> I don't imagine everyone fits the criteria of the question, but I am up for

> an annual review if

> whether I should be allowed to stay on Xolair. I have been on one year, and

> my assumption is

> that it is policy for Anthem CA to have the patient re-submit a new prior

> authorization every

> 6-12 months. I remember vaguely a conversation here about someone who

> improved

> clinically on Xolair and was taken off because his/hers numbers went outside

> the criteria

> range to stay on the drug. Stupid we can all agree, but despite my IgE

> (before Xolair 355 and

> after 525) still within the criteria, my positive tests for aeroallergens

> while on Xolair, my lung

> functions have improved enough (>80% for FEV1) to say that I don't require

> the drug. Of

> course the idiotic logic is that it was supposed to help my lung functions.

> However, my

> doctor has told me that Anthem might want to see me fail again in order to

> put me back on

> it. Clearly I know this is all about money, but I feel like a lab rat.

>

> Just for anyone's edification, if lung functions improve because of Xolair,

> that should be a

> logical outcome and not a reason for removal from the drug. However, if IgE

> numbers

> plummet AND positive tests for aeroallergens are negative while on Xolair,

> then that might

> justify a period of time off the drug. I will let you know what happens, but

> I have begun to

> prepare to have to fight to stay on the drug because I did so well on it.

> Crazy

>

>

>

>

>

>

[Guest guest]

Personally, I think that some insurance companies don't want to pay

for such an expensive drug and try to find any loophole they can to

not approve it. A person's serious health condition is not as

important as the almighty dollar. Sad.

Fortunately, my insurance has always seen my need and has paid with no

problems at all for over 5 years. It has kept me out of the ER which

saves them much more money.

Doug

Group founder/co-owner

[Guest guest]

I find that very odd. My lung function has NEVER been a

consideration for Xolair authorization. Regardless, any one with

common sense would say that your improvement in lung function is

PRECISELY why you should be reauthorized.

Addy

Group co-owner

Generally annoying know-it-all (can't help it - Duke grad - GO BLUE

DEVILS)

> >

> > I have Anthem BC of CA and have not had to fill out any

paperwork . I have

> > been getting Xolair for over 2 years now and have never had a

review. It

> > might be how your employer (or those who offer the plan) have it

set.

> >

> >

> >

> > B.

> >

> >

> >

> > From:

[mailto: ] On

> > Behalf Of billybaroo1958

> > Sent: Saturday, December 27, 2008 11:55 AM

> >

> > Subject: [ ] Reauthorization by Athem-CA

> >

> >

> >

> > I don't imagine everyone fits the criteria of the question, but I

am up for

> > an annual review if

> > whether I should be allowed to stay on Xolair. I have been on one

year, and

> > my assumption is

> > that it is policy for Anthem CA to have the patient re-submit a

new prior

> > authorization every

> > 6-12 months. I remember vaguely a conversation here about someone

who

> > improved

> > clinically on Xolair and was taken off because his/hers numbers

went outside

> > the criteria

> > range to stay on the drug. Stupid we can all agree, but despite

my IgE

> > (before Xolair 355 and

> > after 525) still within the criteria, my positive tests for

aeroallergens

> > while on Xolair, my lung

> > functions have improved enough (>80% for FEV1) to say that I

don't require

> > the drug. Of

> > course the idiotic logic is that it was supposed to help my lung

functions.

> > However, my

> > doctor has told me that Anthem might want to see me fail again in

order to

> > put me back on

> > it. Clearly I know this is all about money, but I feel like a lab

rat.

> >

> > Just for anyone's edification, if lung functions improve because

of Xolair,

> > that should be a

> > logical outcome and not a reason for removal from the drug.

However, if IgE

> > numbers

> > plummet AND positive tests for aeroallergens are negative while

on Xolair,

> > then that might

> > justify a period of time off the drug. I will let you know what

happens, but

> > I have begun to

> > prepare to have to fight to stay on the drug because I did so

well on it.

> > Crazy

> >

> >

> >

> >

> >

> >

[Guest guest]

Actually it is a requirement, on the prior authorization form used by Wellpoint

Pharm: IgE

level of greater than 30, one positive test of an aeroallergen and a FEV1 below

the 80th

percentile.

> > >

> > > I have Anthem BC of CA and have not had to fill out any

> paperwork . I have

> > > been getting Xolair for over 2 years now and have never had a

> review. It

> > > might be how your employer (or those who offer the plan) have it

> set.

> > >

> > >

> > >

> > > B.

> > >

> > >

> > >

> > > From:

> [mailto: ] On

> > > Behalf Of billybaroo1958

> > > Sent: Saturday, December 27, 2008 11:55 AM

> > >

> > > Subject: [ ] Reauthorization by Athem-CA

> > >

> > >

> > >

> > > I don't imagine everyone fits the criteria of the question, but I

> am up for

> > > an annual review if

> > > whether I should be allowed to stay on Xolair. I have been on one

> year, and

> > > my assumption is

> > > that it is policy for Anthem CA to have the patient re-submit a

> new prior

> > > authorization every

> > > 6-12 months. I remember vaguely a conversation here about someone

> who

> > > improved

> > > clinically on Xolair and was taken off because his/hers numbers

> went outside

> > > the criteria

> > > range to stay on the drug. Stupid we can all agree, but despite

> my IgE

> > > (before Xolair 355 and

> > > after 525) still within the criteria, my positive tests for

> aeroallergens

> > > while on Xolair, my lung

> > > functions have improved enough (>80% for FEV1) to say that I

> don't require

> > > the drug. Of

> > > course the idiotic logic is that it was supposed to help my lung

> functions.

> > > However, my

> > > doctor has told me that Anthem might want to see me fail again in

> order to

> > > put me back on

> > > it. Clearly I know this is all about money, but I feel like a lab

> rat.

> > >

> > > Just for anyone's edification, if lung functions improve because

> of Xolair,

> > > that should be a

> > > logical outcome and not a reason for removal from the drug.

> However, if IgE

> > > numbers

> > > plummet AND positive tests for aeroallergens are negative while

> on Xolair,

> > > then that might

> > > justify a period of time off the drug. I will let you know what

> happens, but

> > > I have begun to

> > > prepare to have to fight to stay on the drug because I did so

> well on it.

> > > Crazy

> > >

> > >

> > >

> > >

> > >

> > >

[Guest guest]

I think your doctor handles all the stuff you don't see. The prior

authorization is normally done through internal communications with

the doctor and pharmacy. My problem thus far with the process was

that Wellpoint never contacted my doctor to get a new authorization,

they just let the old one expire. So, when it came to re-fill

monthly as I do, they wouldn't refill. My contention was that they

shouldn't have contacted my doctor when the new authorization was

needed. However, the one caveat is that I am currently under

the " pharmacy plan " and eligible for self-injection. It is possible

that Wellpoint's policy is that the patient is reponsible to

initiate a new authorization. But, here is the twist....my script

ran out in September. It was refilled by doctor, and Precision RX

continued to refill on the new script. Apparently, to write a new

prescription and to get a new authorization are not the same thing.

As for the criteria to get on Xolair, I believe that is part of the

FDA guideline. What made it possible for me last year was that the

IgE and positive tests for aeroallergens were never an issue in the

many, many years I have had asthma. But, my pulmonary function tests

were always in the 90-110 percentile. I was a long distance runner,

biker andd climber. My functions only really dropped when I had a

cold or flu or if I was stupid enough to eat something I was

allergic to and then go exercise (EIA w/ an allergic component).

Then two years ago, my allergic immune system whacked out after I

got a viral respitory infection. My functions dropped into the 70

percentile. Xolair got me back to 90th percentile again. Thus, here

is sit wondering whether I will get kicked off because I improved.

> > >

> > > Well it has nothing to do with my employer. I talked to

Wellpoint

> > who are the pharmacy

> > > plan for Anthem and my insurance, so I likely has to with the

> > former. When Wellpoint

> > > authorized Xolair last year they only wrote the authorization

for

> > one calendar year. I got

> > > the sense from the people at Wellpoint that this how they

write the

> > approval for Xolair for

> > > everyone. The silliness is that theoretically the doctor can

say

> > one still needs to take

> > > Xolair, document this and still be turned down by the review

doctor

> > at Wellpoint by saying

> > > " we don't think the drug is a medical necessity " . Ideally,

Xolair

> > is intended to improve lung

> > > function and/or allergic reactions and alter Ige levels. So,

the

> > reviewer can say, " the new

> > > lung functions results don't fit the criteria to take the

drug " ,

> > because of course I improved

> > > on the drug. My doctor has already prepared me for the

possibility

> > that Wellpoint will want

> > > to see me fail off it, in order to put me back on it.

Personally, I

> > think it is just that they

> > > don't want to pay for the drug.

> > >

> > >

> > >

> > > --- In

> <mailto: %40> , " Belsky " <crdb@>

wrote:

> > > >

> > > > I have Anthem BC of CA and have not had to fill out any

> > paperwork . I have

> > > > been getting Xolair for over 2 years now and have never had

a

> > review. It

> > > > might be how your employer (or those who offer the plan)

have it

> > set.

> > > >

> > > >

> > > >

> > > > B.

> > > >

> > > >

> > > >

> > > > From:

> <mailto: %40>

> > [mailto:

> <mailto: %40> ] On

> > > > Behalf Of billybaroo1958

> > > > Sent: Saturday, December 27, 2008 11:55 AM

> > > >

> <mailto: %40>

> > > > Subject: [ ] Reauthorization by Athem-CA

> > > >

> > > >

> > > >

> > > > I don't imagine everyone fits the criteria of the question,

but I

> > am up for

> > > > an annual review if

> > > > whether I should be allowed to stay on Xolair. I have been

on one

> > year, and

> > > > my assumption is

> > > > that it is policy for Anthem CA to have the patient re-

submit a

> > new prior

> > > > authorization every

> > > > 6-12 months. I remember vaguely a conversation here about

someone

> > who

> > > > improved

> > > > clinically on Xolair and was taken off because his/hers

numbers

> > went outside

> > > > the criteria

> > > > range to stay on the drug. Stupid we can all agree, but

despite

> > my IgE

> > > > (before Xolair 355 and

> > > > after 525) still within the criteria, my positive tests for

> > aeroallergens

> > > > while on Xolair, my lung

> > > > functions have improved enough (>80% for FEV1) to say that I

> > don't require

> > > > the drug. Of

> > > > course the idiotic logic is that it was supposed to help my

lung

> > functions.

> > > > However, my

> > > > doctor has told me that Anthem might want to see me fail

again in

> > order to

> > > > put me back on

> > > > it. Clearly I know this is all about money, but I feel like

a lab

> > rat.

> > > >

> > > > Just for anyone's edification, if lung functions improve

because

> > of Xolair,

> > > > that should be a

> > > > logical outcome and not a reason for removal from the drug.

> > However, if IgE

> > > > numbers

> > > > plummet AND positive tests for aeroallergens are negative

while

> > on Xolair,

> > > > then that might

> > > > justify a period of time off the drug. I will let you know

what

> > happens, but

> > > > I have begun to

> > > > prepare to have to fight to stay on the drug because I did

so

> > well on it.

> > > > Crazy

> > > >

> > > >

> > > >

> > > >

> > > >

> > > >