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California Medical Insurance Plans That Cover Actemra
Polymyalgia Rheumatica (PMR) | Last Active: Jul 7, 2023 | Replies (9)Comment receiving replies
My rheumatologist at Kaiser Permanente Northern California (KPNC) gave me the following enlightening information:
1. If I rejoin KPNC privately after retiring from my employer, I will be given the same rheumatologist and primary care physician that I previously had.
2. Since my rheumatologist has already been treating me with Actemra (aka Tocilizumab), there would be no question about continuing this treatment. It would be entirely routine.
3. Even through Actemra is not on the KPNC "formulary" (ie list of Kaiser insurance-covered drugs), it would be deemed "medically necessary" by any rheumatologist at KPNC. Actemra would therefore would be covered by my KPNC insurance due to this "exception".
4. Since Actemra would be deemed "medically necessary", my insurance coverage, and my personal costs, would be consistent with any drug on the KPNC formulary list.
5. No other authority or approval is required for Actemra to be covered. Coverage only requires that the treating physician check a box in an online form confirming that Actemra is "medically necessary". This is done routinely.
The answers I received from KPNC Member Services did not entirely agree with this. They implied that getting a doctor to prescribe Actemra, even though I am currently being treated with it, might be difficult. Further, they seemed to imply that even if my doctor submitted a new request for me to be treated with Actemra, that request might be denied.
My rheumatologist strongly disagreed with KPNC Member Services on these issues. I decided to trust him.
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My experience with member benefits with KPNC is that they know less than medical specialists when it comes to medical necessity regarding medications, etc. not on the Kaiser formulary or FDA approved. I was denied serum tears for a severe eye condition prior to my PMR diagnosis although Kaisers Regional Corneal Specialist said it was covered. We persisted and I’m now receiving Vital Tears at no cost made from my blood because it’s a blood product not a medication.
In January I had onset PMR following a Shingles vaccine.
The corneal specialist said there was no inflammation in my eyes relieving fears of GCA. In May, my vision declined and the same specialist noted inflammation in both eyes but from allergies. This is being treated with prednisone drops along with my oral doses for PMR. Very scary. I return for a checkup next Thursday. With fingers crossed I pray for good news.
My rheumatologist said my temporal artery pulse is good and inflammatory markers are down so not GCA. I’m approaching 5mg of prednisone hoping my adrenal gland will function and I can smoothly finish taper in 5 months.