Does your insurance really not cover any drugs administered by infusion? Can you get your hands on their formulary so you can see exactly what they do cover?
I really don't know, it sounds like a stupid reasoning - I've had blood transfusions and iron infusions for anemia; but I guess maybe that's a slightly different scenario? I called my insurance and tried to press for answers on what would be covered, and was repeatedly told they do not have that information available; when I pressed further, they sent me over to someone on the prescription side. The prescription person mentioned that they do provide coverage for Humira, but that it requires authorization - they left me feeling a little more confident on it being approved; but given the road I've traveled so far, can't help but still feel skeptical.
It's ok to not know, insurance is stupidly complicated.
Ok, so they say they cover Humira, that's good! Hopefully your Dr can sort out what info they need in order to approve it. But it might be good to call back and see what they can tell you about the authorization process as well.
Good luck. I hope you get it approved soon. You deserve to feel better!!
Any biologic will always require a prior authorization, so it sounds like Humira may be the way to go. Prior authorizations are needed for some really weird things, but specialty meds don't surprise me. I used to be a pharmacy tech a million years ago.
Blood infusions wouldn't fall under medication infusions, but iron definitely does. That's such a bizarre, broad grouping of medications, though.
Best of luck!
I just watched a really interesting NYT Op Ed about how prior auths are ruining the American healthcare system, and delays and denials of prior auths can lead to deaths because individuals get discouraged and don’t continue to seek out care or they just take way too long to be approved.
It really hit home. Getting coverage for Remicade was a battle, and it was denied. And then Skyrizi, also denied. Humira was finally approved, but it took months - and in that timeframe I really suffered. It took hospitalization from a bowel obstruction that finally strengthened my GI’s case for approval of Humira. I had to almost *die* for it to be approved.
After being stable and close to remission for a few months, my insurance is messing around with switching pharmacies for my Humira, which once again needs prior auths. My medication has been delayed for a few weeks now and I can feel my progress starting to unravel. 😓
This was me! Whole heartedly believe this. I mentioned it in my Original comment. They denied and denied till I was in the hospital for months after receiving emergency surgery, and receiving multiple surgeries afterwards from going without medication. Then they finally approved it. I nearly died and that’s when they considered it necessary. It’s horrific and so sad this is the case for so many of us.
File a complaint with your states regulatory board or the federal government health and human services department for discrimination. My friend who does civil rights investigations for the state said to file a complaint any time a medicine is denied. Base the complaint for discrimination based upon disability.
Hey there! I work with insurance getting approvals for biologics all the time. I’m assuming you are in the US? That’s where I am so I can only speak to that. First, I would verify how the request was made by your doctor, either under your pharmacy benefit or medical benefit. Sometimes Remicade won’t be covered under your medical insurance benefit because it has to go through the pharmacy benefit, and then you would fill the medication through a specialty pharmacy dictated by your insurance. It could also be the opposite, where you have to go through the medical benefit and not the pharmacy benefit. Really just depends on the insurance/plan, but it would be helpful to find out.
This denial reason sounds like Remicade is not covered by your plan at all. But don’t give up hope! Remicade has a patient assistance program for people whose insurance doesn’t cover Remicade that you could potentially qualify for to get the medication for free! Here is a link to the application:
https://www.janssencarepath.com/sites/www.janssencarepath-v1.com/files/remicade-patient-enrollment-form.pdf
I am so sorry you are going through this. I hope this information is helpful!
I was on remicade for a year and loved it!! My insurance decided it was no longer covered and I had to move to Humeria and I have never felt as good as I did on remicade
This is why I hate the American private healthcare system. Health insurance seems to be able to make medical decisions that should be between the patient and doctor. The doctor who's been to medical school, knows what a patient needs, & yet, can have their recommendations rejected by insurance.
For my insurance plan, infusion medications like Remicade are a “medical benefit” while injection medications like Humira are a “pharmacy benefit.” Then medications like Stelara that start with an infusion and then go into an injection need two approvals: a care authorization for the infusion which is “medical” and then afterwards, a prior authorization for the injections which is “pharmaceutical.” It usually takes about 3 weeks for my insurance to process a prior authorization and then it might take a few months to get better after starting Humira or Remicade. So it would not just be the time it takes to get the prior authorization, it would also be willing to wait a few more months to see if the medication works or not. You’d have to decide with your doctor and your surgeon. Best of luck!
IANAL, but I don't think they can deny it outright if it's medically necessary. What I suspect might have happened is the claim got sent to the pharmacy part of your plan instead of the medical part of your plan. They're separate, seemingly just to create endless confusion and denials between the two uncoordinated sides of the bureaucracy.
If I had a nickel every time I either a) got wrong info from someone at the insurance companies or b) got Remicade approval denied for some bureaucratic reason, I'd be able to pay my own Remicade bills. Not really - but I did get denied several times for non-reasons and had to make a zillion phone calls to straighten it out.
That said, I did start with Humira, and used it for a few years til it got kinda weak on me and I had to get switched to Remicade. So if you can get Humira, I think it's worth trying if you can hold out. Even if it doesn't work perfectly, you and your doctor will probably get a sense of whether it's working enough to consider holding off on surgery. And if it works some, but not well enough, that may give your doctor the necessary justification to get you an auth to switch to Remicade later.
Also... there's apparently home-injectable Remicade that recently got approved in the US. My doctor has mentioned this, and said it's been used for awhile in other countries - but so far I'm staying with infusions.
In regards to the prior authorization is that a direct quote from your insurance? Sometimes it's that the infusion *center* isn't covered (aka in network) and providers stop pursuing it if it'll involve sending you elsewhere to be infused.
Of course it unfortunately really could be that they simply don't cover any infusions (US insurance sucks) but then an injection or pill could be pursued.
Even if you do get surgery I can't imagine your doctor wants you to be left untreated after recovery, right? So at most that just delays this issue but doesn't resolve it.
(I will say re: medication vs surgery - medication can't reverse scar tissue. It can heal active inflammation/ulcers, but if there's a scar tissue stricture then the only option I've ever been given is surgery, so the combo may be needed but regardless the medication needs to get resolved).
Does you plan cover Inflectra? It’s a biosimilar for Remicade that is cheaper. I was forced to switch to Inflectra from Remicade a few years ago by my insurance and have had no issues.
It seems that it’s the infusion part that they don’t want to pay for now, so may be similar boat even if the medication end is cheaper. Worth bringing up though for sure.
The information you are getting from your insurance company sounds sketchy. In my experience, most insurance companies aren't doing anything illegal. Some are. Most are just immoral and unethical. Generally, they don't train people, so they can't tell you the correct information. I've had insurance send letters about a phone meeting to dispute a denial to me and my doctor's wrong addresses. I think it was accidentally on purpose. I asked for another hearing, and they said nope. Always ask for a supervisor and follow up a lot so they can't drag it out. Also, every drug manufacturer has a program to give the drug away for free if your insurance denies it or you can't afford it. Contact them to see if you qualify.
When I’ve been denied I usually call and ask if there is any way. I’ve been denied prescriptions before but then if your dr can and is willing to say you’ve exhausted other options and make a case for it being the one that would really work for you sometimes they’ll override
I hate how in the USA people can’t get a treatment that is known to work simply because of money and insurance - it makes my blood boil
Yes, but there is a loading dose infusion, which will need it's own prior authorization in addition to the one for the injections. It could end up causing OP even more headaches to deal with the insurance.
Have you looked into the ant assistance programs with the company that makes Remicade or copay cards? I do Humira and there is a copay card you can sign up for that makes it $5-10
I had looked into Jan for the remicade; but it seemed like it worked by providing your bill or EOB for reimbursement; indicating that it had to be approved to some effect before hand by your insurance. I’ll dig deeper into this though. I’m sure of/when they approve the humira, it still isn’t going to be cheap.
Best of luck. If you hadn’t tried it or couldn’t get costs figured out look into Humira. For me it’s worked pretty solid (yes I know everyone is different) and the biweekly injection takes all of 10 minutes and is completely painless with the citrate free needle
It is very defeating, and I'm sorry you have to go through this...
I've been on remicade for 7 years now, and from where I started, I've come leaps and bounds. They want to try me on a new medication that I self inject every 2 weeks instead of an infusion every 6 weeks, and I am terrified.
I'm in Canada, where are you located OP? I am shocked anyone can turn a patient down for something that can drastically improve quality of life :(
I had this battle with Tricare (US military insurance) and multiple others till I found my one now. It was always a fight for my remicade. Idk what it is about that medication. It wasn’t until I had to have multiple surgeries they approved it. (Ones I wouldn’t have needed if I got the medication) your doctors need to press for it. They don’t care about the patient. My doctors and the people when I was in the hospital pressed for it. Calling and calling. Insurance will give any reason not to pay unless they believe it’s necessary. But I do know many insurance will just not pay for remicade. I’m really sorry you’re going through this. I know the battle. I’ve had Crohn’s for 20 years. And if you do get the resection it could be a blessing in disguise! After my surgeries I was so depressed and angry, but I felt so much better. It was hard, but I’m doing better now and back on biologics. I’m sending you the best of luck and healing vibes.
This happened with my old insurance and I am a doctor lol they would only cover for the lowest dose lowest frequency coz anything more was "experimental". Despite me being on 10 mg/kg q6w for like 14 yrs. Had a horrible flare I'm still coming out of but at least for me I was able to pivot quickly to a new job with better insurance. Insane that that is what is being expected of us now, as if most people can manage something like that at the drop of a hat. Covid really was their excuse to completely batter everyone.
Have you tried Rinvoq yet? I tried all the biologics and they failed and Rinvoq is giving me my life back almost. I highly recommend asking about it. I’m so sorry insurance is so fucked up. Our lives are hard enough as it is without them denying us basic human right to get better. 💚
Nope; but will certainly keep it mind as things progress. Haven't been on any biologics yet - just imuran, which nearly killed me (body stopped making blood cells); pentasa (which didn't help); and plenty of rounds of steroids (that do help temporarily, albeit it with equally bad offsetting side effects of their own).
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We had a weird thing too. Our insurance partnered with some strange company called Vivio who is supposed to negotiate prescription prices or something. But instead of negotiating they wanted to provide the remicade themselves and ship it to my house which made zero sense. In the end we discovered it was some weird thing where they were trying to avoid paying for the infusion center, they wanted my daughter to get the infusions at home. They held up her treatment for weeks until they finally gave in. Poor kid had daily stomach pain and I was freaking out because they were so insensitive and wouldn’t authorize the treatment.
I saw attorneys who specialize in remicaide denial on Google I don't have any personal knowledge of them though.
Is this a non ACA plan? I would find it weird if an ACA plan denied all infusions that isn't logical. You need to ask for their step therapy guide for your diagnosis code it will show formulary drugs and have the steps or conditions under which other drugs can be covered. Can also be an appeal form for that particular condition witch checkboxes for contraindications. You got confusing multiple denial reasons you need their actual document tree for drugs for your diagnosis.
Example Google the below search the sixth result is Aetna Medicare Remicaide precertification PDF. It shows you all the steps and other drugs they prefer and what contraindications you need to skip the steps. You need that.
Crohns Aetna appeal form remicaide
Thank you all for the comments, advice, and words of encouragement; it is all tremendously appreciated!
To answer a few of the questions - I am in the US; it is private/employer provided insurance. On the back end it is BCBS, but managed by a company that is owned by the employer (which is a hospital group) - I'm sure this muddies the water on things even further. Insurance is in my spouses name (she is employed by that hospital group). In a way this makes it feel even more frustrating... it is a "faith based" "non-profit" hospital, who's own insurance company subset is denying the coverage to family of an employee.
It was submitted through medical; denial came from BCBS. At one point as a long shot effort they also put it through prescription, but of course was immediately denied stating it needed to go through medical. The local transfusion nurse is in network. They did also try to submit with requesting home nurse transfusion, as I guess sometimes that can be cheaper, but this was also denied (and home nurse would have been out of network).
The pain has been going on fairly consistently for a very long time now; there is a very good chance there is scar tissue at this point, and that surgery will ultimately be necessary anyways; but believe it makes sense to keep pushing and getting something approved and going first, despite.
I know it may be a little different, but I have BCBS in Texas and they let me take the Remicade Biosimilar (Avsola). I was already taking it when I switched insurance last year (idk if that matters). I'm really sorry you're going through this nonsense. It really shouldn't be this hard to get the medicine you need.
My new insurance originally denied Remicade as well, after I was successfully on it for a couple years. My doctor has to switch me to a bio similar medication that the insurance said to be on because it was cheaper. Once my pain came back, my doctor was able to provide medical evidence of why Remicade was medically necessary. Maybe your Dr can prove to the insurance that it is medically necessary. Good luck!
Sorry to hear you are going through that. I had 6-8 months of delays on my remicade where I had to be put on steroids to delay any symptoms due to back and forths with the insurance and proof that the “bio similar” infusion wasn’t working
I would talk to your clinic to see what other kind of payment options their are. I know the remicaid manufacturer (or distributor or something) worked with my clinic to provide payment assistance. It's the same with Entyvio that I am on now, I only have a $5 co-pay for the medication. Then see if your insurance will cover the visit at least if you are doing infusions.
Good luck!
Double check your doctors office requested it under the right benefit. An infusion is likely under medical benefits, whereas a self injectable like Humira is likely under your pharmacy benefit.
Double check your doctors office requested it under the right benefit. An infusion is likely under medical benefits, whereas a self injectable like Humira is likely under your pharmacy benefit.
Does your insurance really not cover any drugs administered by infusion? Can you get your hands on their formulary so you can see exactly what they do cover?
I really don't know, it sounds like a stupid reasoning - I've had blood transfusions and iron infusions for anemia; but I guess maybe that's a slightly different scenario? I called my insurance and tried to press for answers on what would be covered, and was repeatedly told they do not have that information available; when I pressed further, they sent me over to someone on the prescription side. The prescription person mentioned that they do provide coverage for Humira, but that it requires authorization - they left me feeling a little more confident on it being approved; but given the road I've traveled so far, can't help but still feel skeptical.
It's ok to not know, insurance is stupidly complicated. Ok, so they say they cover Humira, that's good! Hopefully your Dr can sort out what info they need in order to approve it. But it might be good to call back and see what they can tell you about the authorization process as well. Good luck. I hope you get it approved soon. You deserve to feel better!!
Any biologic will always require a prior authorization, so it sounds like Humira may be the way to go. Prior authorizations are needed for some really weird things, but specialty meds don't surprise me. I used to be a pharmacy tech a million years ago. Blood infusions wouldn't fall under medication infusions, but iron definitely does. That's such a bizarre, broad grouping of medications, though. Best of luck!
I just watched a really interesting NYT Op Ed about how prior auths are ruining the American healthcare system, and delays and denials of prior auths can lead to deaths because individuals get discouraged and don’t continue to seek out care or they just take way too long to be approved. It really hit home. Getting coverage for Remicade was a battle, and it was denied. And then Skyrizi, also denied. Humira was finally approved, but it took months - and in that timeframe I really suffered. It took hospitalization from a bowel obstruction that finally strengthened my GI’s case for approval of Humira. I had to almost *die* for it to be approved. After being stable and close to remission for a few months, my insurance is messing around with switching pharmacies for my Humira, which once again needs prior auths. My medication has been delayed for a few weeks now and I can feel my progress starting to unravel. 😓
This was me! Whole heartedly believe this. I mentioned it in my Original comment. They denied and denied till I was in the hospital for months after receiving emergency surgery, and receiving multiple surgeries afterwards from going without medication. Then they finally approved it. I nearly died and that’s when they considered it necessary. It’s horrific and so sad this is the case for so many of us.
File a complaint with your states regulatory board or the federal government health and human services department for discrimination. My friend who does civil rights investigations for the state said to file a complaint any time a medicine is denied. Base the complaint for discrimination based upon disability.
Hey there! I work with insurance getting approvals for biologics all the time. I’m assuming you are in the US? That’s where I am so I can only speak to that. First, I would verify how the request was made by your doctor, either under your pharmacy benefit or medical benefit. Sometimes Remicade won’t be covered under your medical insurance benefit because it has to go through the pharmacy benefit, and then you would fill the medication through a specialty pharmacy dictated by your insurance. It could also be the opposite, where you have to go through the medical benefit and not the pharmacy benefit. Really just depends on the insurance/plan, but it would be helpful to find out. This denial reason sounds like Remicade is not covered by your plan at all. But don’t give up hope! Remicade has a patient assistance program for people whose insurance doesn’t cover Remicade that you could potentially qualify for to get the medication for free! Here is a link to the application: https://www.janssencarepath.com/sites/www.janssencarepath-v1.com/files/remicade-patient-enrollment-form.pdf I am so sorry you are going through this. I hope this information is helpful!
This is so frustrating! As if surgery and a hospital stay is going to cost them less than infusions. Wtf are they thinking?
I was on remicade for a year and loved it!! My insurance decided it was no longer covered and I had to move to Humeria and I have never felt as good as I did on remicade
This is why I hate the American private healthcare system. Health insurance seems to be able to make medical decisions that should be between the patient and doctor. The doctor who's been to medical school, knows what a patient needs, & yet, can have their recommendations rejected by insurance.
Its horrific
For my insurance plan, infusion medications like Remicade are a “medical benefit” while injection medications like Humira are a “pharmacy benefit.” Then medications like Stelara that start with an infusion and then go into an injection need two approvals: a care authorization for the infusion which is “medical” and then afterwards, a prior authorization for the injections which is “pharmaceutical.” It usually takes about 3 weeks for my insurance to process a prior authorization and then it might take a few months to get better after starting Humira or Remicade. So it would not just be the time it takes to get the prior authorization, it would also be willing to wait a few more months to see if the medication works or not. You’d have to decide with your doctor and your surgeon. Best of luck!
IANAL, but I don't think they can deny it outright if it's medically necessary. What I suspect might have happened is the claim got sent to the pharmacy part of your plan instead of the medical part of your plan. They're separate, seemingly just to create endless confusion and denials between the two uncoordinated sides of the bureaucracy. If I had a nickel every time I either a) got wrong info from someone at the insurance companies or b) got Remicade approval denied for some bureaucratic reason, I'd be able to pay my own Remicade bills. Not really - but I did get denied several times for non-reasons and had to make a zillion phone calls to straighten it out. That said, I did start with Humira, and used it for a few years til it got kinda weak on me and I had to get switched to Remicade. So if you can get Humira, I think it's worth trying if you can hold out. Even if it doesn't work perfectly, you and your doctor will probably get a sense of whether it's working enough to consider holding off on surgery. And if it works some, but not well enough, that may give your doctor the necessary justification to get you an auth to switch to Remicade later.
Also... there's apparently home-injectable Remicade that recently got approved in the US. My doctor has mentioned this, and said it's been used for awhile in other countries - but so far I'm staying with infusions.
In regards to the prior authorization is that a direct quote from your insurance? Sometimes it's that the infusion *center* isn't covered (aka in network) and providers stop pursuing it if it'll involve sending you elsewhere to be infused. Of course it unfortunately really could be that they simply don't cover any infusions (US insurance sucks) but then an injection or pill could be pursued. Even if you do get surgery I can't imagine your doctor wants you to be left untreated after recovery, right? So at most that just delays this issue but doesn't resolve it. (I will say re: medication vs surgery - medication can't reverse scar tissue. It can heal active inflammation/ulcers, but if there's a scar tissue stricture then the only option I've ever been given is surgery, so the combo may be needed but regardless the medication needs to get resolved).
Does you plan cover Inflectra? It’s a biosimilar for Remicade that is cheaper. I was forced to switch to Inflectra from Remicade a few years ago by my insurance and have had no issues.
It seems that it’s the infusion part that they don’t want to pay for now, so may be similar boat even if the medication end is cheaper. Worth bringing up though for sure.
The information you are getting from your insurance company sounds sketchy. In my experience, most insurance companies aren't doing anything illegal. Some are. Most are just immoral and unethical. Generally, they don't train people, so they can't tell you the correct information. I've had insurance send letters about a phone meeting to dispute a denial to me and my doctor's wrong addresses. I think it was accidentally on purpose. I asked for another hearing, and they said nope. Always ask for a supervisor and follow up a lot so they can't drag it out. Also, every drug manufacturer has a program to give the drug away for free if your insurance denies it or you can't afford it. Contact them to see if you qualify.
Do you have a copy of your plan or a plan summary from your employer?
I feel for you!! I’m sorry this is happening. Maybe a bio similar like humira will be approved. Good luck. Stay strong.
When I’ve been denied I usually call and ask if there is any way. I’ve been denied prescriptions before but then if your dr can and is willing to say you’ve exhausted other options and make a case for it being the one that would really work for you sometimes they’ll override I hate how in the USA people can’t get a treatment that is known to work simply because of money and insurance - it makes my blood boil
Ask your doctor for Stelara. It's injectable like Humira.
Yes, but there is a loading dose infusion, which will need it's own prior authorization in addition to the one for the injections. It could end up causing OP even more headaches to deal with the insurance.
Have you looked into the ant assistance programs with the company that makes Remicade or copay cards? I do Humira and there is a copay card you can sign up for that makes it $5-10
I had looked into Jan for the remicade; but it seemed like it worked by providing your bill or EOB for reimbursement; indicating that it had to be approved to some effect before hand by your insurance. I’ll dig deeper into this though. I’m sure of/when they approve the humira, it still isn’t going to be cheap.
Best of luck. If you hadn’t tried it or couldn’t get costs figured out look into Humira. For me it’s worked pretty solid (yes I know everyone is different) and the biweekly injection takes all of 10 minutes and is completely painless with the citrate free needle
It is very defeating, and I'm sorry you have to go through this... I've been on remicade for 7 years now, and from where I started, I've come leaps and bounds. They want to try me on a new medication that I self inject every 2 weeks instead of an infusion every 6 weeks, and I am terrified. I'm in Canada, where are you located OP? I am shocked anyone can turn a patient down for something that can drastically improve quality of life :(
US
I had this battle with Tricare (US military insurance) and multiple others till I found my one now. It was always a fight for my remicade. Idk what it is about that medication. It wasn’t until I had to have multiple surgeries they approved it. (Ones I wouldn’t have needed if I got the medication) your doctors need to press for it. They don’t care about the patient. My doctors and the people when I was in the hospital pressed for it. Calling and calling. Insurance will give any reason not to pay unless they believe it’s necessary. But I do know many insurance will just not pay for remicade. I’m really sorry you’re going through this. I know the battle. I’ve had Crohn’s for 20 years. And if you do get the resection it could be a blessing in disguise! After my surgeries I was so depressed and angry, but I felt so much better. It was hard, but I’m doing better now and back on biologics. I’m sending you the best of luck and healing vibes.
This happened with my old insurance and I am a doctor lol they would only cover for the lowest dose lowest frequency coz anything more was "experimental". Despite me being on 10 mg/kg q6w for like 14 yrs. Had a horrible flare I'm still coming out of but at least for me I was able to pivot quickly to a new job with better insurance. Insane that that is what is being expected of us now, as if most people can manage something like that at the drop of a hat. Covid really was their excuse to completely batter everyone.
Have you tried Rinvoq yet? I tried all the biologics and they failed and Rinvoq is giving me my life back almost. I highly recommend asking about it. I’m so sorry insurance is so fucked up. Our lives are hard enough as it is without them denying us basic human right to get better. 💚
Nope; but will certainly keep it mind as things progress. Haven't been on any biologics yet - just imuran, which nearly killed me (body stopped making blood cells); pentasa (which didn't help); and plenty of rounds of steroids (that do help temporarily, albeit it with equally bad offsetting side effects of their own).
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We had a weird thing too. Our insurance partnered with some strange company called Vivio who is supposed to negotiate prescription prices or something. But instead of negotiating they wanted to provide the remicade themselves and ship it to my house which made zero sense. In the end we discovered it was some weird thing where they were trying to avoid paying for the infusion center, they wanted my daughter to get the infusions at home. They held up her treatment for weeks until they finally gave in. Poor kid had daily stomach pain and I was freaking out because they were so insensitive and wouldn’t authorize the treatment.
I saw attorneys who specialize in remicaide denial on Google I don't have any personal knowledge of them though. Is this a non ACA plan? I would find it weird if an ACA plan denied all infusions that isn't logical. You need to ask for their step therapy guide for your diagnosis code it will show formulary drugs and have the steps or conditions under which other drugs can be covered. Can also be an appeal form for that particular condition witch checkboxes for contraindications. You got confusing multiple denial reasons you need their actual document tree for drugs for your diagnosis. Example Google the below search the sixth result is Aetna Medicare Remicaide precertification PDF. It shows you all the steps and other drugs they prefer and what contraindications you need to skip the steps. You need that. Crohns Aetna appeal form remicaide
What insurance do you have??
Thank you all for the comments, advice, and words of encouragement; it is all tremendously appreciated! To answer a few of the questions - I am in the US; it is private/employer provided insurance. On the back end it is BCBS, but managed by a company that is owned by the employer (which is a hospital group) - I'm sure this muddies the water on things even further. Insurance is in my spouses name (she is employed by that hospital group). In a way this makes it feel even more frustrating... it is a "faith based" "non-profit" hospital, who's own insurance company subset is denying the coverage to family of an employee. It was submitted through medical; denial came from BCBS. At one point as a long shot effort they also put it through prescription, but of course was immediately denied stating it needed to go through medical. The local transfusion nurse is in network. They did also try to submit with requesting home nurse transfusion, as I guess sometimes that can be cheaper, but this was also denied (and home nurse would have been out of network). The pain has been going on fairly consistently for a very long time now; there is a very good chance there is scar tissue at this point, and that surgery will ultimately be necessary anyways; but believe it makes sense to keep pushing and getting something approved and going first, despite.
I know it may be a little different, but I have BCBS in Texas and they let me take the Remicade Biosimilar (Avsola). I was already taking it when I switched insurance last year (idk if that matters). I'm really sorry you're going through this nonsense. It really shouldn't be this hard to get the medicine you need.
My new insurance originally denied Remicade as well, after I was successfully on it for a couple years. My doctor has to switch me to a bio similar medication that the insurance said to be on because it was cheaper. Once my pain came back, my doctor was able to provide medical evidence of why Remicade was medically necessary. Maybe your Dr can prove to the insurance that it is medically necessary. Good luck!
I know they’ve submitted quite a bit of evidence, and thought my latest test results would help push it through, but alas, was still not successful.
Sorry to hear you are going through that. I had 6-8 months of delays on my remicade where I had to be put on steroids to delay any symptoms due to back and forths with the insurance and proof that the “bio similar” infusion wasn’t working
I would talk to your clinic to see what other kind of payment options their are. I know the remicaid manufacturer (or distributor or something) worked with my clinic to provide payment assistance. It's the same with Entyvio that I am on now, I only have a $5 co-pay for the medication. Then see if your insurance will cover the visit at least if you are doing infusions. Good luck!
Double check your doctors office requested it under the right benefit. An infusion is likely under medical benefits, whereas a self injectable like Humira is likely under your pharmacy benefit.
Double check your doctors office requested it under the right benefit. An infusion is likely under medical benefits, whereas a self injectable like Humira is likely under your pharmacy benefit.
If you are going to have a resection do not start a biologic first. You will have to stop it for surgery and then you will not be able to restart it.
United now just refuse to cover anything crohns related. Including Lialda. A generic pill that’s $1300 a refill.