Share Facebook
Crohn's Disease Forum » Treatment » Remicade/Infliximab » Pre-Authorization for Remi?


11-07-2016, 10:14 PM   #1
Mehita
Forum Monitor
 
Mehita's Avatar
 
Join Date: Nov 2011
Location: Minnesota

My Support Groups:
Pre-Authorization for Remi?

Just got a letter from our insurance company today stating that they did a review of my son's files and we now need to have his GI do a pre-authorization for Remicade starting January 1, 2017. I'm really worried that insurance will deny it and we'll have to work through the appeals process, maybe even postpone his January infusion.

He's been on Remicade for three years now with no prior approvals needed. He's at a higher dose than the FDA standard (7.5mg/kg & 6 weeks). He's doing great.

What have others experienced with insurance pre-authorizations? Appeals processes? I guess I'm hoping for the best, but planning for the worst.
__________________
Mom of DS, age 17, dx Crohn's and Celiac Oct 2008
- Remicade, started Nov 2013, added Solumedrol June 2015
- added Methotrexate/Folate March 2016
- Multivitamins, Probiotics, Vit D
- Small bowel resection, Jan 2013
11-07-2016, 10:42 PM   #2
northwesterner
 
Join Date: Mar 2013

My Support Groups:
Just got a letter from our insurance company today stating that they did a review of my son's files and we now need to have his GI do a pre-authorization for Remicade starting January 1, 2017. I'm really worried that insurance will deny it and we'll have to work through the appeals process, maybe even postpone his January infusion.

He's been on Remicade for three years now with no prior approvals needed. He's at a higher dose than the FDA standard (7.5mg/kg & 6 weeks). He's doing great.

What have others experienced with insurance pre-authorizations? Appeals processes? I guess I'm hoping for the best, but planning for the worst.
Step 1: Google the name of the insurance company, and "remicade." For the most part, the big insurers have a copy of their authorization policy and the necessary criteria to be met posted online. Once you read what they're looking for to give the "ok" you'll know whether this is just a paperwork issue or if you're heading into a battle.
11-07-2016, 10:47 PM   #3
Mehita
Forum Monitor
 
Mehita's Avatar
 
Join Date: Nov 2011
Location: Minnesota

My Support Groups:
Thanks, Northwesterner. Blue Cross actually included that info in the letter they sent. Part of the reason I'm a little concerned is because my son is at a higher dose and frequency than the FDA recommendation and they mention that as a criteria in the letter.

Of course, I'm assuming the FDA recommendation is 5mg/kg and 8 weeks. We did Prometheus testing prior to his dose increase and at 8 weeks he has 0 Remi in him. I'm just hoping this is all enough "proof" that he's where he needs to be.

I hate insurance hassles.
11-08-2016, 12:37 AM   #4
northwesterner
 
Join Date: Mar 2013

My Support Groups:
Got it. Just wanted to make sure you took a look. In the decade+ I've been dealing with insurance and biologics, we've gone from totally opaque approval policies and criteria to the current setup where the basic approval policies are posted online, which makes it a lot easier to figure out.
11-08-2016, 03:00 AM   #5
Maya142
Forum Monitor
 
Maya142's Avatar
You should be ok Mehita. As long as the doctor can make a case for it, which he can.

We were able to get 10 mg/kg every 4 weeks approved for Crohn's. And later, for M's arthritis, "high dose Remicade" - 20 mg/kg every 4 weeks.

We have to do prior authorization every time we switch biologics (which unfortunately, has happened many times for M) and sometimes it happens very quickly (within 5-6 days) and other times it takes a while (weeks).

I think since he's been on Remicade for a while, and you have evidence that he needs a higher dose, it should be pretty straightforward and will hopefully come through quickly. Good luck!
__________________
Mom of M (20)
diagnosed with Crohn's Disease at 16
Juvenile Idiopathic Arthritis at 12
Juvenile Ankylosing Spondylitis at 16

Mom of S (23)
dx with JIA at 14
Ankylosing Spondylitis at 18
11-08-2016, 08:54 AM   #6
Lisa
Adminstrator
 
Lisa's Avatar
 
Join Date: Apr 2010
Location: New York

My Support Groups:
I went from an annual pre-authorization to every 6 months a couple years ago. My infusion clinic/GI does all the paperwork, make sure you are on good terms with the office staff lol.....the receptionist/secretary at the clinic automatically submits for pre-authorization, only once has there been an issue where the paperwork was 'lost' - and she was right on top of it and got things straightened out so I could get my infusion on time.
__________________

30 plus years and counting with UC/Crohn's!
on remicade since 11/05

While my experiences may not be what everyone has had- I feel it is worthwhile to share any and all experiences that may be beneficial to others.
11-08-2016, 09:22 AM   #7
my little penguin
Forum Monitor
 
Join Date: Apr 2012

My Support Groups:
Same here the orignal approval
For the med is only good for so many years
Three years is typical
Then you need re approved
We have gone through this for ds humira
Good luck
__________________
DS - -Crohn's -Stelara
11-30-2016, 12:36 PM   #8
DougUte
Senior Member
 
DougUte's Avatar
 
Join Date: Jul 2010
Location: Kaysville, Utah

My Support Groups:
I am going through this with Humira right now. The FDA guideline is one injection every two weeks. My G.I. changed me to weekly injections. The Prometheus test showed my Humira level was 2.1. At a minimum it should be 5.0. So we had evidence showing I needed the increase. Weekly injections is above the FDA recommended dosage for Humira. My insurance company has denied the weekly Humira, even though we had the evidence of needing the dosage increased.
__________________
Surgery Oct 12, 2010

Crohns Medicines:
Started Humira June 22nd, 2011
Increased to weekly injections on November 1st, 2016
Due to the insurance company, Humira ended on January 31, 2017.
Started Entyvio February 9th, 2017
Loperamide 3 capsules twice a day
Vitamin B6, B12, Folic Acid
Vitamin D3 10000 I.U.
Nature Made Multivitamin
Reply

Crohn's Disease Forum » Treatment » Remicade/Infliximab » Pre-Authorization for Remi?
Thread Tools


All times are GMT -5. The time now is 02:50 AM.
Copyright 2006-2017 Crohnsforum.com