I have been put on an expensive anti Cholesterol drug at the start of the year and all started out well except we did not hear from CPAM at first so contacted them and we’re told if you do not hear from us in two week it is approved.
I took it for four months and my Cholesterol dropped to normal levels.
Then as we were told we asked our MT to renew the Ordonnance and he told us he could not as it was not on AMELI Pro.
Back to the Cardio who wrote a new Ordonnance which again went to CPAM . this time we get a letter back saying denied. There are other cheaper drugs (they had already been told I could not take them)
So we appealed rending all the supporting info, we then got another letter saying they would consider this but if we did not hear in two months we could take it to the Tribunal Judicial.
Well it is now over two months and we have heard nothing so we are sending a letter with all the info off to the TJ.
Stella Thank you for that, I need to look into that a bit more but from a preliminary look I think I am on the first one « contester une décision administrée » and we have been through that process CRA and as they have not responded in the two months they told me in a letter, we have to take the next step.
The next step in their letter is to take them to the Tribunal. Both of my Consultants Cardiolog and Rhumatologist and my MT all agree I am an ideal candidate for the drug we know it works for me so I will continue to pursue it.
High Cholesterol means I have needed three stents, the Cardio wanted to put me on Statins ( the cheaper option) but I took those for about 7 years and they have caused another rare condition ( Necrotising Immune Médiated Myopathy)
The Cardio then came up with antiPCSK9 inhibitors which work well but cost about €800 a month. Yes I could start paying for them myself and have been thinking of doing so but getting the money back might be a problem. It is not immediately life threatening but I don’t want any more stents.
Don’t even think of going litigation, you will never win here. As Stella says the Médiateur de la République is the way to go and will try and stop any very very expensive court costs which could put you in the poor house literally.
I am so sorry that you are having to go through all of this.
I was refused ALD status for my, even more expensive drug than yours. My MT went back and I did get ALD for my prescriptions.
Like David Spardo I cannot access my Ameli account, so I totally agree about the administration being a mess.
Several years ago I took the Cleiss to the EU because they were denying me access to treatment in UK because I had an S1 and was in the French system.
It took two years but, eventually, they admitted that they had misunderstood the regulations.
The UK then changed their affiliation to the EU health agreements, which was cheaper for them but meant that anyone going back to UK with an S1 did not have to wait 6 months to rejoin the NHS,
In view of people going back to UK after Brexit, this must have helped them quite a lot.
Take cheer, you can win.
Thanks Jane. I have ALD status and all my medical team are onboard with the drug but just cannot seem to get it approved after CPAM messed up the first prescription by not putting it On AMELI Pro. When it was resubmitted it should have been straightforward but someone at AMELI screwed up ( they won’t admit that)
When the Pharmacist tried to sort it she was told that he doesn’t need the drug as his Cholesterol is low. She then rightly pointed out that that was after four months taking the drug.
With regards the Tribunal from what I have read it should be quite straightforward a question of resubmitting my paperwork sent to AMELI who will then need to defend their decision and I do not need an Avocat so should not be too expensive!!
Just a few comments from my experience with CPAM Agen, which I do hope will be helpful. Firstly, Ameli is just the internet portal for the health service, it’s definitely the CPAM that you will be dealing with and who, by the sound of things, screwed up.
Briefly, we contested the decision to refuse our application for the complémentaire santé. Nothing had changed in our circumstances but it was refused nonetheless. After several face-to-face appointments to try to find out why, we were grudgingly given a copy of an internal memo from the Ministre de Santé. We were told to apply as French, (having acquired French nationality back in 2018) but that application was refused as well. We were told to appeal to the Mediator. What most folks don’t realise is that the mediator is just one of the employees of the relevant CPAM. Surprise! Their decision was upheld.
It never went to the Tribunal, but I suspect that with the backing of your MT, Cardio and pharmacien you’ve got a very strong case and they’ll back down. Good luck!
Go onto the Ameli site and immediately a pop-up box asks you to confirm your local CPAM via your postcode. Once you’ve done that, log in and on the RH side under ‘Agenda’ there’s a box with ‘Prendre un RDV’. I don’t know about your CPAM but online is the only way now to get a RDV. You have to wait outside too, until someone deigns to come and let you in
We didn’t pursue our case and eventually the British Embassy succeeded in getting a law change in Brits’ favour. It shook our love for the country to its foundations, though, having jumped through all the hoops to become French citizens.
Hi thanks for that info. I finally succeeded in getting through on the phone and actually spoke to someone who confirmed that they had both of my dossiers. I sent it again in case they had managed to loose the first one. Although I sent it Avis de reception I still wondered if they had it and if it had gone to the right department.
He promised they would look at it and get back to me later in the week. Fingers crossed. In the post this morning I received a copy of a letter to AMELI from my Medicine Interne ( Rhumatologist) putting my case again and copying it to my MT and Cardiologist.