So I've been dealing with pouchitis basically since my take-down last summer. My GI wants to me (and so do I ) to try VSL3-DS as a maintenance drug(probiotic).
My insurance company has rejected it twice and now I need to appeal it which I will ask my GI to do (shouldn't be a problem).
Has anyone had success getting their insurance company to approve a new script for VSL-DS in the past year? I've read that they are cracking down on Food and Probiotic reimbursement.
Any suggestions?
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I was successful about a month ago after an appeal process that included my state insurance department and took over a year. It's important to know exactly what their grounds for denial are. It helped me that my coverage included all prescription meds, just at a higher copay for the most expensive "tier."
Thanks Scott,
I am a still waiting for the 2nd rejection letter in the mail. First time they denied it due to it being food related item and not a drug.
I have a PPO and I haven't run into an issue before with coverage and I was surprised how much they covered with my pharmacy copays (tiers) most stuff falls under tier 1 & 2. I guess I shouldn't of sent the coverage book that insurance company sent me to the recycling center.
At some point if the GI can't get it approved then I'll appeal it to the State Insurance Board (NY).
For now I will just stick with the regular VSL-3.
I wrote a medical necessity letter, complete with footnotes from the medical literature, for my doctor to put on his letterhead. Some of it is specific to my insurance company's particular excuse for denial, but other parts might be useful to any medical necessity appeal. Just PM me if you need some text and I'll be glad to edit it down and share it.
Thanks Scott,
I might take you up on that offer in the future if the GI can't get it done. It's the best suggestion that I've heard in regards to getting approval of VSL.
Wow this sounds a lot like me, I have had pouchitis basically since takedown last summer too. I have actually always been able to have my insurance cover VSL 3 but I think because its a new year now, that I would have to pay a deductible of 580$ :/
Ive been on VSL very sporadically but I also want to try it again to be able to get off of the antibiotics that I have been on since summer!
So frustrating that insurance will not have a smaller co pay.
I wish I'd been fighting a high copay. Several insurers have stopped covering it at all. At full retail (which has fluctuated at my pharmacy), the maximum dose of 4 packets/day adds up to $7,000-$8,000 per year.
But my insurance company has no problem paying for Xifaxan or Entocort, each cost $1,700 a month.
I was told that if I did get VSL-3 DS approved that it would be a $50 copay which is what I pay out of pocket for VSL-3. So I'd like to try the stronger VSL3-DS version.
The way I see it (which the insurance company doesn't care about) is that it is a chance to get me off the expensive antibiotics, steroids, office visits and expensive scopes.
