Jacie is an active teenager who enjoys being a competitive cheerleader as well as an honor roll student. But Jacie is not your typical high schooler because since 4th grade she has battled Juvenile Arthritis.
Jacie has many major joints affected with Arthritis including hands, fingers, knees, elbows, hips, back, ankles, and toes. To help control her pain and prevent joint deformities she has tried and failed on numerous immunosuppressive medications that are administered by infusion or injection, including Humira, Enbrel, Orencia, and Actemra.
After many months without relief of pain and symptoms her rheumatologist prescribed Simponi; another strong immunosuppressive medication. Immediately, their Express Scripts (a prescription drug management company) denied her request. The ‘letter of denial’ from her insurance suggested she try other drugs that Jacie had already taken and did not help stop the progression of her disease. “Our doctor sent in an appeal and was denied again”, commented Susan, Jacie’s mother.
On January 1, 2018, Jacie’s drug insurance changed to CVS Specialty. Once again, her rheumatologist submitted a request to CVS Specialty for Simponi prescription and again it was denied. Susan spoke to the CVS prior authorization agent three times. It was explained to her that Simponi was not one of the “covered” drugs for her condition. The drugs on the CVS list that were ‘covered’ and her only options had all been tried by Jacie and had failed to help her. Susan questioned,” How could someone who was not a rheumatologist override our doctor’s decision?”
In the meantime, Jacie’s arthritis has worsened. She is now in severe back and hip pain. At times walking and sitting are both painful. Her hands are stiff and swollen all the time. Jacie experiences great difficulty from opening bottles to walking for the first time since she was diagnosed. “It is very frustrating to watch my child get sicker by the day because of insurance companies’ ‘fail first’ policies. I am a teacher, who is covered under the State Health Benefit plan. This should not be happening. Our rheumatologist should be able to spend her time treating patients not fighting insurance companies”, replied Susan in desperate frustration.