What to do if health insuance denies drug coverage?
My wife has some very complicated medical issues that mostly affect the quality of her life. She lives with headaches that never go away and has constant facial numbness. Some days her headaches are severe. She has been through two craniotomies not mentioning several neurologists. The first surgery was more of a biopsy while the second one was a more open type. Both times the doctors were looking for benign tumors or inflammation located in the cavernous sinus. The first surgery resulted in an inconclusive diagnosis while the second surgery provided answers. It turned out it was neither of the two but something rare that does not have any treatment options.
Due to her medical condition, she took short term disability. While on short term disability, her job was eliminated. She had the choice of working part time with no benefits or continue with disability on a long term basis. She chose the long term disability which eventually turned into social security disability. Her COBRA insurance ended in November and I had to put her on my health insurance plan. My understanding is that she is not yet eligible for Medicare due to an 18 month waiting period from the start of disability.
In October, her doctor came up with a treatment plan to use a drug that is typcially used to treat another disease. His argument being that people typically diagnosed with the one disease typically have a form of the disease that affects my wife. The doctor consulted with other doctors and the consensus was that this would be a plausible treatment option.
Her health insurance had no problem approving this drug. However, under my plan, they have denied coverage for the drug. The doctor did an emergency appeal but we were again denied. The health provider denied her coverage because the drug is only approved for certain diagnosis and my wife's condition is not one of them. However, there are no drugs that are available to treat her condition. The cost of this drug is in the $8,000 to $10,000 range for a month's supply. We can't afford paying for the drug out of pocket. Meanwhile, my wife is severely depressed.
