Insurance (Anthem) denying Remicade

Anthem has denied our second appeal to cover Remicade for our 15 year old son. They say he does not qualify because he has not been on any other meds yet. He was diagnosed and had small bowel resection in October. Our pediatric GI is rated #1 in the country--how can they go against recommendations?

Any tips on how to convince Anthem to cover the Remicade?

Thanks!

Sorry I don't have any advice on how to convince them. Have you spoken to the GI since the second denial, if so what has he had to say. Have you sent them any studies that show top down therapy is proven effective? You may want to search for some of those and print them out. I am assuming the GI has already sent a letter stating his recomendation. So sorry you are having to go through this. Hopefully someone will be along with experience with Anthem or insurance denial.

Thanks, Clash! We have a GI appointment in 2 weeks and they said we would talk about starting a different med then (they did not specify which one). They sent copies of research studies with the appeal and our nurse said she tried to explain it to the Anthem person. I forgot to mention that Anthem also denied our doctor's request to do a 'peer-to-peer' call w/ the Anthem medical director because they said it would not make a difference.

We have told the GI that we are willing to pay for the Remicade ourselves if that is necessary, but they keep discouraging us from doing that. I know it is very, very expensive. But if that is what our son needs, we would find a way to make it work. And still continue to get Anthem to change its mind as well.

In Quebec, Canada we have the option to have a private insurance or be covered by the public system. if you have a private insurance no worries however when you are covered by the public system you have to have tried everything else before they will pay for Remicade. i gather that they want to save as much money as possible by trying something less expensive first.

my suggestion would be to try the more traditional treatments first, if they fail then Remicade would probably be approved then.

Thank you boogie & clash. While I am certainly going to keep bugging the insurance company about the remicade, it looks like we might start w/ methotrexate. We'll talk to the GI on the 31st.

I did call the Remicade support line, and they referred me to the Johnson & Johnson patient assistance foundation (www.jjpaf.org). They have a form to fill out and send in to see if they will help pay for the Remicade. Although it appears to be income based and more for those without insurance, the person I talked to said it is possible to get assistance even if you don't meet that criteria. It is worth a shot for anyone going through this!

Does your son have a crohn's dx? I went straight to remicade on blue cross but I had to have a crohn's diagnosis.

flowergirl said:

Does your son have a crohn's dx? I went straight to remicade on blue cross but I had to have a crohn's diagnosis.

Click to expand...

Yes--he has the Crohn's diagnosis. Since my original post about this, he has gone on budesonide and has lost weight. The GI doc is going to use that info for a third appeal.

Would your doctor consider prescribing Humira for your son instead? Humira is also a biologic medication and it might be less expensive than Remicade.

I have gone through a few meds and I am now on Remicade. Still no change with the med but I am staying focused. I live in SoCal and go to St. Joseph Medical for all my treatments. I have seen the bills they send to the insurance company and it is crazy what they bill for. Almost $29,000 for just the first 2 infusions. We all know they never get paid this amount and that cash is king. However, the med itself costs over $1,400 or so.

It does sound bad that they are pushing back but even at 25% the payment. The infusions are costly. Try some other meds and see if they work. You may get lucky

Look up a program called Remistart.

some insurance companies are like that. I have migraines that are very very bad. And before my Neuro RNNP could try the Botox injections I had to be on every medication to treat it that's out there. I did and nothing worked so she sent the paper work requesting the shots and tons of supporting documentations that every med I was on either didn't work, had a very bad side effect, or had a serious drug interaction and she wasn't going to risk my life.

Centocor, maker of Remicade does have a program for those who can't pay for the treatment if they are self pay. They can provide assistance. Most drug companies won't help out if you do have coverage, it's mainly for the self pay as I cld the drug company for Humira and asked if they could help with my $30 copay ONE time as funds were tight for us 3 years ago. They said NO. Unless I had no coverage, they refused to help me.

Give Centocor a call anyway and explain your situation. doesn't hurt to try.

Remi start will help with a lot of it for the first year and then there is a different program for the second year.
Sorry you have to go through this.
I do know for our insurance they made a change this year where you have to fail all of the cheaper drugs before they will approve the pricey ones.

Good luck -- they never make it easy

http://www.remistart.com/

http://www.remistart.com/for_patients/remistart_extended_access_program.html

I may be a latecomer to the forum but I'm having the same problems with Anthem after many years of being covered by other Blue Cross/Blue Shield insurance companies. My job automatically switches people to Anthem last year but I was promised the same coverage as Empire Health choice (but better, they promised...yeah, right! More money for co-payments and payment denials!).

So last year, I was taking Remicade for January and March (the final infusion after being showed that I've recovered) and I thought "all is well" (taking Azathioprine and Famotidine daily) but then I get a notice from Anthem saying they're denying payment of those last two Remicade treatments saying I haven't tried other possibilities (???).

When I explained, "Check my medical records and you'll see I've tried other treatments." the "nice" lady on the phone says, "We're basing our judgement on 2013." despite my doctor trying to convince them I needed the treatments.

Anyway, I've checked out Anthem's Remicade approval rules and fit the criteria.
(I'm too "new" to post the link but Google "Anthem Remicade approval" and you'll see a pdf file with the Remicade "Approval Criteria")
I will appeal as much as possible but if Anthem continues to deny coverage, I was told by the hospital that I'm free to use their legal services against Anthem (as a last resort). I'll keep everyone informed even if it takes a few months as these people are slow in response and the people answering the phones don't know anything but "No!"

So did anyone else here tried to appeal after Anthem denial and won? I'd like to see if it's possible to successfully appeal without resorting to suing them!

It took 6 months, but we did finally get Anthem to approve Remicade for my son. My husband ended up calling the person in charge of benefits at his company's corporate office and explaining what our son went through and why we wanted the Remicade. She told us to submit a formal appeal (again!) as well as a letter from us. I wrote the letter, explained everything, listed the credentials of our GI and basically said that if the head of GI at one of the top children's hospitals in the country is recommending Remicade for our son, then we trust that it is the right thing to do. I don't know if it was the letter, or the appeal with the help of the person at corporate, but we got the approval within weeks.

Good luck...if I've learned anything, it is never give up!

Thank you! That's very encouraging! They (Anthem) have a heart after all that paperwork!

Habbymomma- we have same problem! Anthem has denied our son Remicade because we haven't tried other treatments. But our son has a fistula and Remicade is the only drug to treat that. We live in Cincinnati and see docs at Children's. Can you please tell me with whom you spoke at Anthem? I also feel like we have the best docs treating our son, but some random dopey doctor at Anthem who knows nothing about medicine but just a bottom line is making the decisions. Ever heard that joke: "What do you call the person who graduated last in their class from medical school?" The answer: "Doctor." That is Anthem.

I'm so sorry you are having trouble. And I thought a fistula would have gotten our son approved right away!

First, make sure to appeal the decision through the proper channels. Your GI nurse should be able to do this, but follow up to make sure it is done correctly. At some point, part of the appeals process is a "peer to peer" phone call between your GI and Anthem's MD. Even if Anthem says this will not change their decision, push for it.

Finally, someone at Anthem told me that my husband's employer could over-ride Anthem and instruct them to cover the Remicade. But it would be setting a precedent that my the employer may not want to set. When it really looked like we were not going to ever be approved, my husband contacted the benefits analyst at the corporate HQ. She talked to Anthem, sent all the paperwork through again, and told us to send a letter telling our side of the story.

I wrote a letter to Anthem describing our son's situation, how Crohn's has affected him, and how prestigious Dr Denson and Children's is. I can send you a copy if you want to give me your email address. It was just after they got the letter that they finally approved the Remicade.

I hope this helps! Let me know if you want a copy of the letter.

So grateful I found this thread! My son sees Dr. Saeed at Cincinnati children's. We currently have United Health Care but my husband's company is switching to Anthem early next year. I am so sorry to hear you have had to deal with so many issues from them. I am wondering if it is just the changing climate of health care in general and if all health insurance companies are making changes? I know that ours has been charging more, covering less, and denying some tests etc.

Thanks for the great info!!

I know our insurance changed this year - making it so all lower level drugs have to be tried first /proven failure before they will approved upper level drugs ( biologics in this case).
It wasn't an issue for DS since he started out at the bottom and worked his way up to humira.

Thank you so much Habbymomma! I sent a private message. But I wanted everyone to know about Anthem's appeal process. Our doctor had a peer review with someone at Anthem about 2 weeks ago. Denied. So my husband and I wrote an appeal last week. An Anthem appeal has to be done online, and the appeal itself cannot be longer than 56 characters. Characters! Barely any space to say anything. After reading your post last week, I contacted my employer. She told me to have the doc appeal again, and then if that didnt work to contact her again. So now it is a waiting game. Funny, because under Anthems/Express Scripts Remicade qualifications states anyone "over age of 6 and who has had fistulizing Crohns for more than 3 months." My son should automatically qualify.
Johnnysmom- we see Saeed too!