Otezla Insurance Denial Attorney in California
Psoriatic arthritis (PsA) is a condition that causes chronic inflammation, which, in turn, results in skin plaques and joint pain. When a person’s immune system mistakenly attacks their joints and skin, causing swelling and pain, the condition may be diagnosed as PsA. If PsA is left untreated, permanent joint damage can occur over time. About a third of all those with psoriasis – a skin disease that causes a rash with itchy, scaly patches – will develop PsA. PsA is different from rheumatoid arthritis, although the characteristics are similar.
Rheumatoid arthritis typically does not present with plaques, while PsA usually presents with plaques on the skin as well as other symptoms. If your doctor has prescribed the drug for your PsA only to have Otezla denied by insurance, you may be frustrated, even angry. After all, you faithfully pay your insurance premiums and follow the rules only to have a drug your doctor considers necessary for your condition denied.
What is Otezla?
Otezla (apremilast) is a drug that treats psoriasis and psoriatic arthritis by regulating cell inflammation. The drug inhibits an enzyme (phosphodiesterase 4 or PDE4) that controls inflammation at the cellular level. When prescribed, the first five days are considered a “start period,” during which the dosage is gradually increased until 30 mg twice daily is reached. Otezla is often used with other treatments, including topicals and phototherapy, and has been shown to be safe and effective when used with methotrexate.
Diagnosing psoriatic arthritis usually starts with a patient with stiff, sore joints, movement pain, and skin plaques. The doctor will look for signs of joint swelling, tenderness, and pain, take blood tests, and have X-rays and an MRI done to help pinpoint the source of the inflammation. Otezla is known as a biologic as it targets specific parts of the immune system linked to inflammation. Other treatments for psoriatic arthritis may include immunosuppressants, disease-modifying antirheumatic drugs, and nonsteroidal anti-inflammatory drugs. However, Otezla and drugs like it have shown some of the best results.
Who Gets Psoriatic Arthritis?
While anyone can develop psoriatic arthritis, it is most common among adults and often develops in those already diagnosed with psoriasis – about seven to ten years after the skin symptoms began. In some cases, a stressful event, a serious infection, or trauma to the joints or bones can trigger psoriatic arthritis. In addition to scaly, inflamed patches of skin – usually on the knees, elbows, or scalp – joint stiffness in the neck, lower back, and hips can quickly turn to chronic pain and loss of mobility.
A person with psoriatic arthritis may also experience chronic fatigue, a lack of energy, painful swelling of a whole finger or toe, tenderness where tendons and ligaments attach to bones, eye inflammation, and changes in the appearance of fingernails. Some people diagnosed with psoriatic arthritis may also develop inflammatory bowel disease. Research has found that some people diagnosed with psoriatic arthritis have a family history of the disease while also pointing to environmental factors as a trigger for the onset of the disease.
Why Might Your Otezla Prescription Be Denied?
When an insurance company denies a prescription, it could be because the paperwork was incomplete or had an error, prior authorization may have been required, which was not obtained, or the medication could have been specifically denied in your insurance plan. Some of these issues can be resolved, and the claim can be re-submitted. Generally speaking, insurance companies oftentimes deny the most expensive drugs and treatments.
These denials may come in the form of the insurer saying the drug is not medically necessary or is experimental. Since Otezla can cost between $5,000 and $6,000 a month, it is more likely that the insurance company simply does not want to pay for it. If your Otezla is denied by insurance, you do have options and do not have to simply accept this decision.
What Should You Do if Your Insurer Denies Your Otezla Prescription?
For Otezla denied by insurance, you can first file an internal appeal. This internal appeal asks your insurance company to take another look at their prior denial and make a different decision. Including a letter from your doctor that details why the drug is so important for your medical condition can be extremely helpful.
If your insurance company continues to deny your prescription for Otezla, you can, with the help of an attorney, file an external appeal. An external appeal asks a neutral third party to look at all the facts and approve the drug prescribed by your doctor. If this third party does approve the treatment, your insurance company must abide by the decision.
What Companies Are More Likely to Deny Treatments Like Otezla?
While any insurance company can deny a treatment, some seem more likely to do so than others. A woman in New York was denied Otezla by her insurer. Her doctor provided information that showed the woman had tried and failed topical steroids and had been doing well while using Otezla samples.
The health insurer offered alternatives that were not appropriate for the patient as she was not a good candidate for systemic medications because she was of childbearing age. This made abiologic medication like Otezla a good treatment. The patient had no adverse side effects from Otezla, making it medically appropriate and necessary. The appeal overturned her insurer’s initial denial of treatment, forcing them to pay for her treatment. Some of the most common California insurers include:
- Anthem Blue Cross
- Blue Shield
- Health Net
- Kaiser
- Cigna
- Aetna
- Medi-Cal Managed Care Plans (Anthem Blue Cross, Promise Health Plan, Health Net, Molina)
How the Law Offices of Scott Glovsky Can Help With Your Otezla Denial
Otezla denied by insurance can be disheartening. You need someone in your corner who will aggressively fight for you and will never hesitate to go up against a huge insurance company on your behalf. Attorney Scott Glovsky fights injustice on a daily basis against insurers who believe they are untouchable. When you choose the Law Offices of Scott Glovsky, you are no longer fighting on your own. Scott Glovsky could be your last chance to get the justice you deserve, and he takes that responsibility very seriously, fully committing himself to each of his clients. Contact the Law Offices of Scott Glovsky today.