Mended Hearts Open Forum

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Repatha Medicine Denial Help

  • 1.  Repatha Medicine Denial Help

    Posted 08-23-2019 23:46
    Back in Nov 2018, I had a mild heart attack.  My family history of high blood pressure, heart disease (dad's first heart attack at 42), diabetes, high cholesterol both mother and father.  I got everything from both sides of my family.   I eat a heart health/diabetes healthy diet.   Yet nothing I do can get my cholesterol down.

    After the heart attack, I was put on statins.   Within a few weeks, I began to notice mild memory loss that got worse and worse and worse until one day, I went to Cardiac Rehab, parked, got out and could have sworn I locked my car.   Came back out almost two hours later only to find my car running and unlocked.   From that point on, I checked multiple times because I couldn't remember if I had turned the car off and locked it.  I would get to my location and take my foot off the break to get out of the car only to find, I had not put the car in park.

    My primary care doctor reduced the dosage, which didn't help and at my next visit, my cardiologist took me off the statin and tried to get me on Praluent.  Insurance denied it and said I needed to try more statins.   So my cardiologist changed to a different statin and lower dosage.   Memory issues started returning.   My cholesterol numbers started rising.    So she took me off that and tried to get me on Repatha.     My primary care physician had two months of samples while we worked through the appeal trying to get this.   I've had no negative side affects of Repatha.  My appeal has been denied twice.  Insurance company wants me to try more statins which  I'm terrified of trying more due to the memory issues.   My primary care physician that I'm just one of those that can't take statins.

    I don't qualify for low cost or free medication due to income level.  But there's no way I can pay over $1000 per month for the medication.  While I'm waiting, my cholesterol continues to rise.   I guess I'm just going to have to wait until I have another heart attack or a stroke.

    Any help on getting insurance to change their mind on this or another way to get this medication?

    Appreciate all help.

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    Elizabeth Anderson
    Dallas TX
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  • 2.  RE: Repatha Medicine Denial Help

    Posted 08-24-2019 03:27
    Dear Elizabeth,

    Do you get your health insurance through a job or some other group like a labor union or some kind of membership association?  If so, there may be someone at the job or group that handles insurance matters who can intercede with the insurer on your behalf.

    In a worst case scenario, I would be happy to ask colleagues at the Dallas office of my law firm if they can recommend a lower cost lawyer in your area that handles these types of issues with whom you could consult.

    Please keep us posted and let us know if you need assistance finding an appropriate lawyer in your area.  If you want to discuss trying to find a lawyer privately, you can reach me at ira.reid@bakermckenzie.com.

    Best of luck,

    Ira Reid


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    Ira Reid
    Hoboken NJ
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  • 3.  RE: Repatha Medicine Denial Help

    Posted 08-24-2019 09:45
    Insurance through my job and HR is clueless and worthless.

    I've sent in for a outside review so we will see what they say.   If that doesn't help - I'm going to go to the state insurance commission and see if I can get help.   And if that doesn't help then I might need that lawyer.   Will keep you posted.

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    Elizabeth Anderson
    Dallas TX
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  • 4.  RE: Repatha Medicine Denial Help

    Posted 08-24-2019 14:47
    Edited by LINDA GRAMZ 08-24-2019 14:55
    Elizabeth:  Here is the information from the website for Repatha:

    Eligibility Requirements for Repatha® Copay Card: Open to patients with commercial prescription insurance and who are not enrolled in any government-funded program that pays for prescription drugs. This program is not open to uninsured patients or patients enrolled in any federal, state, or government-funded healthcare program such as Medicare, Medicare Advantage, Medicare Part D, the Retiree Drug Subsidy Program, Medicaid, Medigap, Veterans Affairs (VA), the Department of Defense (DoD) or TRICARE®, or where prohibited by law. Cash Discount Cards and other noninsurance plans are not valid as primary under this offer.
    If at any time a patient becomes enrolled under any such federal, state, or government-funded healthcare program, he/she will no longer be able to use this card and you must call 1-844-REPATHA to stop participation. Restrictions may apply. Offer subject to change or discontinuation without notice. This is not health insurance. Patients under 18 years of age are not eligible for this program

    I did not see any income requirements with this co pay card.  I have several co pay cards for some of my medications and have never been asked for any proof of income.  If your insurance is not Medicare or any federally funded program you should qualify.

    I fought for my husband's co pay card for Prialta for his pain pump.  He is covered under my group health insurance and Medicare Part B with no drug coverage.  They denied him.  I demanded they prove to me that he would not be eligible as his Medicare does not have any prescription drug coverage and therefore he is not exempt.

    Outcome:  He is fully covered for the Prialt drug co pay card and we only have to pay $5.00 a month.

    These drug companies hire companies that do not understand the regulations and staff that are clueless.


    Good luck

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    LINDA GRAMZ
    MELBOURNE FL
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  • 5.  RE: Repatha Medicine Denial Help

    Posted 08-24-2019 17:16
    Linda, I do have commercial insurance through my employer.  It's United Healthcare.   The $5 co-pay card requires UHC to first approve me using the medications before the co-pay card can be used.   So without UHC approving - I can't use the co-pay.   Repath wants UHC to pay their portion first and then will help me with my portion.  Which my portion if I don't use the $5 co-pay would be $90.   So it's Repatha pay $85 per month vs $1000+ per month for me to get the drug.

    The income requirements are not on the co-pay card but other programs to help low-income people who don't have drug insurance or are on Medicare, Medicaid, etc.   These are through Patient Advocate Foundation & Patient Access Network Foundation.   Both have income requirements that I do not qualify for.  They are truly for low-income.   I'm not low-income but nowhere close to where I can afford $1000+ per month medication.

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    Elizabeth Anderson
    Dallas TX
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  • 6.  RE: Repatha Medicine Denial Help

    Posted 08-25-2019 04:42
    Linda,
    I agree on the co-pay cards mentioned here, I use our hospital pharmacy and they set it up for me for Eliquis ( and earlier for Multaq, when I was taking Multaq) Both are $500 to $600 per month. Eliquis co-pay is $10 per month and Multaq was $0.00. I got off the Multaq when I had cryogenic ablation for atrial fibrillation in December 2017. My cardiologist wants me to stay on the blood thinner- Eliquis to prevent a stroke from a blood clot, should the AFibs return. So, knowing my experience with the co-pay and others experiences here, it appears all PHARM companies have slightly different programs for their co-pays.
    Regards,
    Joe J Ft Myers