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Annoying health insurance company

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  • Annoying health insurance company

    So apparently, my insurance company decided that paralyzed life is too easy. I used to take Enablex in the AM and Ditropan in the PM. I have had bladder Botox and tried stopping both the Enablex and Ditropan, but ended up having bowel accidents once I did that. So I stayed on the two meds until I started reading about Ditropan causing memory/cognitive issues. I have a brain injury and short term memory issues, and I decided that I don't need there to be any chance of the Ditropan making any of my brain injury symptoms worse, so I stopped it. I have not had the bowel issues since stopping Ditropan, but I have noticed a significant increase in my evening leg spasms and pre-AM-medication-spasms. I'm assuming this is because of the Enablex wearing off.

    Just yesterday, I got a letter in the mail from my insurance company telling me that I need to work with my doctor to see if there's a cheaper alternative to the Enablex that will still work with me. I'm quite comfortable in my current medication line-up and have absolutely zero desire to change it up at all. But my insurance company is saying that they're going to stop covering the Enablex in the future if I don't do "step therapy" to see if something else works for me. Why can't they just leave me alone and let me keep things as they are?!? It's hard enough just being paralyzed and dealing with everything that comes with it. I don't need my insurance company twisting the knife!

  • #2
    This is a common issue for the use of newer drugs for any condition. What you need is to have your physician write a letter of medical necessity (which was requested by your insurance) justifying why you need this newer (and more expensive) anticholenergic drug. Given the history you site, I assume your physician knows the reasons that the other drugs don't work for you, but you could outline this for him/her to make it easier for them to write the justification and for you to appeal this decision.

    The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.


    • #3
      This is pretty standard these days. My Dad has these things happen frequently. But since you have been on the med for awhile, just as KLD said... your doctor will just need to call/appeal and explain why you need your medicine. It will probably get approved. Do your best to put together the information for your doctor to make it easy for them... like a reminder list of what you tried in the past (that "failed"), and why you need the current med, and how long you've been on it.