What Is Lupus?
Systemic lupus erythematosus (SLE) is the most common form of lupus, which is an autoimmune disease, The immune system in those with lupus attacks its own tissues, leading to tissue damage and widespread inflammation in the affected organs. Lupus can affect the blood vessels, kidneys, joints, brain, lungs, and skin. SLE symptoms can be mild or life-threatening. The causes of SLE are unknown, yet are believed to be linked to genetic, hormonal, or environmental factors.
Some of the most common symptoms associated with lupus include extreme fatigue, skin rashes, chronic fevers, pain and swelling in the joints and muscles, anemia, hair loss, mouth ulcers, clinical depression, chronic headaches, sensitivity to light, weight loss, and water retention. In some cases, symptoms of lupus may come and go, as the body can go into remission for months, even years, only to have it come back with a vengeance. Early diagnosis and proper treatments can help reduce the effects of SLE, leading to a better quality of life.
Less effective treatments or poor access to care can increase the long-term damages of SLE, increasing the risk of death. Those with lupus may experience a decrease in quality of life—physically, mentally, and socially. The longer a person lives with SLE, the less likely they are to be a part of the workforce. Diagnosing lupus requires blood tests, x-rays, and a physical examination, although a blood test does not always definitively diagnose lupus.
FDA Approved Drugs Used for Treating Lupus
Since lupus can cause a lot of different health problems, there are a variety of medications used to treat it. Antimalarials like Plaquenil (hydroxychloroquine) work by reducing proteins in the blood that attack healthy tissues and cells. Antimalarials—aside from treating malaria—can reduce the pain and inflammation of lupus and prevent flare-ups of lupus as well as the skin problems that may accompany SLE. Drugs like Plaquenil can also help prevent blood clots and organ damage, usually taking1-3 months to begin working.
Steroids, like glucocorticoids, cortisone, or corticosteroids, can be prescribed for lupus to help reduce inflammation and pain. NSAIDs can be used to help control the pain of lupus. These may be OTC NSAIDs like ibuprofen or naproxen (Advil, Motrin, Aleve), or prescription NSAIDs like Relafen, Indocin, or Celebrex. Other types of medications used for lupus include immunosuppressives which prevent the immune system from attacking healthy body tissues. The most common types of immunosuppressives include:
- Rheumatrex (methotrexate)
Anticoagulants like Heparin or Warfarin may be prescribed to prevent blood clots, and monoclonal antibodies (proteins made in a lab that find and attach to specific substances in the body) are also approved to treat lupus. Some of the most common monoclonal antibody drugs include:
- Benlysta (Belimumab)
- Saphnelo (Anifrolumab-fnia)
Are Lupus Treatments Expensive?
While lupus treatments may be covered by health insurance, your insurer may have denied approval for the specific drug prescribed by your physician. The newer biologic treatments can cost as much as $35,000 per year (Benlysta) while a month of hydroxychloroquine can run as much as $500. Not only may insurers refuse to pay for the more expensive lupus treatments, but one study found that about 22 percent of those with lupus fail to take their medications as prescribed due to the cost. So, even when an insurer pays, the co-pay can be prohibitively expensive for many patients.
Can Your Insurance Company Deny Treatment for Your Lupus?
Your doctor might believe the biologic Benlysta would effectively treat your lupus symptoms, yet your insurance company might have denied approval for Benlysta until you have tried and failed other medications like methotrexate. Step therapy is a process used by many health insurers to keep costs down. Step therapy requires patients to take more than one medication that the insurer—not your doctor—determines to be an appropriate treatment.
These alternatives may be generics and are virtually always lower-cost medications. Step therapy can be arduous –not to mention detrimental to your health. You may have to endure months, even years of trying and failing other medications before your insurer will allow you to “step up.” This process places all the power in the hands of your insurer. Individuals often grow weary of the process and give up, simply hoping a sub-par medication will keep them semi-healthy.
Step therapy is common, both in private and public health insurers. If you’ve been subjected to a lengthy step therapy process or have received an outright denial for a drug your physician believes can help your lupus symptoms, you may understandably be frustrated and angry. Some of the insurers that commonly deny necessary prescription medications for lupus include:
What Should I Do if My Health Insurance Company Won’t Pay for My Lupus Treatment?
Dealing with insurance companies can be complex and anxiety-inducing—even more so when you are dealing with an illness like Systemic Lupus Erythematosus. When a treatment that can allow you to live a more normal life—or a treatment that could save your life—is denied, you may not realize that you have options. When your insurer denies a medication, they must notify you of the reason for the denial. You then have the right to file an internal appeal and request an external review if your internal appeal is denied. Because there are deadlines associated with these appeals and reviews, it is essential that you have an experienced attorney by your side who can help you ensure you receive the drug you need. Another reason to have an experienced attorney is that you may want to go a different route than an external appeal
How Can an Attorney Help if I’ve Received an Insurance Denial for Lupus Treatment?
Attorney Scott Glovsky helps those in LA County and across the state of California, with offices in Claremont and Pasadena. If your lupus prescription drug has been denied, Scott can help you combat every single tactic put forth by your insurer. At the Law Offices of Scott Glovsky, Scott and his team will fight on your behalf to ensure your insurance company pays for your lupus medication—a medication your doctor prescribed believing it would help your symptoms. We believe in you and your future and believe you deserve an attorney in your corner who fights for justice on your behalf. Contact the Law Offices of Scott Glovsky today.