Remicade not covered...now what?

Doc is almost ready to start the remicade. I went and checked with my ins and they said it's not covered. Have you experienced this?? Now what

I would appeal the decision. Call them and say you won't accept no for an answer on life saving treatment and want info on appealing the decision. They are required by law to provide that info and hear an appeal.

If that doesn't work there are some orgs that can go to bat for you and others that may provide the Remicade free or at low cost.

Have you checked into Remistart? Here is the link, maybe they can help:

http://www.remistart.com/

We have had things not covered as well. What I did was contact the clinic nurse and tell them you need a prior authorization from her doctor. Usually if a specialist gives a letter they will approve. I hope this helps. Have them do the work, the clinic gets paid to do this kind of stuff.

i asked the ins if the doc could call or write and according to them it wont matter?? Now they cover himeria pen...does that make since? I looked into remistart and u only qualify if ins covers it and copay more then $50. I found johnson and Johnson that would pay for whole thing but u have to not have insurance. i am going to call them Monday and see if they would qualifu me since ins is declining that med all togwther.

i am angry..we have blue cross blue shield pay $97 weekly for a family of 3...i have a ded of $1500 before they start paying 80% and then another ded of $3000..once that iseet then tjey pay 100%. So a month away from ded re starting i have paid NOT ONLY the $97 a week..but $4500 for both ded...hit my 100% for one month!! And plus ally $40 copays for GI and all my copays for meds.
INSURANCE IS SUCH A RIP OFF

OK..VENT OVER

I would still have them do it. Insurance adjusters get paid to deny you. As screwed up as that sounds. I wouldn't listen to the insurance I would have them push for it on the basis of Humira is not usually used in peds unless Remi fails. FWIW the Humira you can do at home so bonus. . I don't think one is safer than the other. They just usually prescribe Remi bc it has had clinical trials. The two are not much different.

The reps on the phone don't know what they are talking about 90% of the time. Tell them you want a manager in the appeals dept and that you want to know the appeal process.

Tell them you are going to the go to the media if they don't cover it. Bad publicity may scare them. You need to be very persistent and not let then bs you.

Fosterfamily2303 said:

Doc is almost ready to start the remicade. I went and checked with my ins and they said it's not covered. Have you experienced this?? Now what

Click to expand...

Did they say why?

One gi I saw wanted to put me on Remicade but said insurance companies won't pay for it UNLESS I've tried other drugs (and failed on them) first.

i have tried all others . the doc says this is my last hope. Only One i have not tried is Humira.

Doc still unsure if i have UC or C.

Fosterfamily2303 said:

i have tried all others . the doc says this is my last hope. Only One i have not tried is Humira.

Doc still unsure if i have UC or C.

Click to expand...

I know that on the Humira website they offer financial support to patients who can't afford the treatment. Perhaps check with the manufacturer of Remicade to see if they can help.

Insurance companies should be forced to pay for whatever treatment the doctors recommend!

https://www3.gotomeeting.com/register/813276550

Wednesday, December 18, 2013 5:00 PM - 6:00 PM PST


Webinar Registration
The cost of care in inflammatory bowel disease (IBD) is significant, and many families struggle with expenses. This webcast, co-presented by CCFA and NeedyMeds, will provide patients and loved ones with tips for managing healthcare costs. Several programs that can help cover the cost of treatment for both uninsured and underinsured patients will be described. Speakers will also discuss disability coverage in IBD.

Straight off the BCBS NC web site regarding coverage -

http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/infliximab.pdf

Not sure if PA has something similar - HOWEVER I did just find this -
https://www.bcnepa.com/Providers/FreedomBlue/9-2-13.pdf -

There should be something in your policy that specifies which drugs are and are not covered - if you don't have a copy of your policy I'd ask for one - you may be able to access it on line too....

Also - make sure they are looking under the MEDICAL BENEFIT - NOT the prescription drug benefit!

pasobuff said:

Straight off the BCBS NC web site regarding coverage -

http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/infliximab.pdf

Not sure if PA has something similar - HOWEVER I did just find this -
https://www.bcnepa.com/Providers/FreedomBlue/9-2-13.pdf -

There should be something in your policy that specifies which drugs are and are not covered - if you don't have a copy of your policy I'd ask for one - you may be able to access it on line too....

Also - make sure they are looking under the MEDICAL BENEFIT - NOT the prescription drug benefit!

Click to expand...

Good thinking...where is my brain? i never received a handbook..i did look online just under remicade and just said not covered...and call rep in hope she would tell me different . But ill Google it. i actually have BCBC of illoness .

thank u everyone.

I know each policy is different even if the carriers are the same. We Have BCBSIL as well, under our contract it is covered under the medical benefit although though it took us a few weeks for that to be straightened out as they kept trying to say it was only covered under the prescription drug benefit.

Clash said:

I know each policy is different even if the carriers are the same. We Have BCBSIL as well, under our contract it is covered under the medical benefit although though it took us a few weeks for that to be straightened out as they kept trying to say it was only covered under the prescription drug benefit.

Click to expand...

i just logged in an re looked and its not. not even under a step threapy managment.

REMICADE(Brand)Solution Reconstituted (Intravenous) - 100mgQty: 1- 1 EA VialFormulary Status:Non-FormularyCoverage Status:Not CoveredUtilization Management:NoneTotal CostEstimate$1012.26$3036.78$1012.26Your CostEstimateNot covered by benefit plan.Not covered by benefit plan.Not covered by benefit plan.

i dont understand why Humira is but remicade is not. Huneria requires a stel threapy managment meaning doc has to explain i have tried all other meds before they approve it

i am very suprissed as BCBSIL has never gave me a problem and had seemed to be very good ins.

Clash said:

I know each policy is different even if the carriers are the same. We Have BCBSIL as well, under our contract it is covered under the medical benefit although though it took us a few weeks for that to be straightened out as they kept trying to say it was only covered under the prescription drug benefit.

Click to expand...

how did u find it covered in the policy vs pharamcy? re never received a handbook so Im doing all research online

Clash said:

I know each policy is different even if the carriers are the same. We Have BCBSIL as well, under our contract it is covered under the medical benefit although though it took us a few weeks for that to be straightened out as they kept trying to say it was only covered under the prescription drug benefit.

Click to expand...

i logged in..amd looked in mail and this was there: Some specialty medications must be given by your doctor or other health care professional and are usually covered under yourmedical benefit. Your doctor will either:Give you these medications in his/her officeRefer you to a Home Infusion Therapy (HIT) provider

so i guess mine may be like yours amd then covered ) THANK YOU for givinh me help and hope!!

Dont knkw why the person i spoke to didnt tell me that.

Our GI nurse told us she thought they were trying to cover it under the prescription coverage and that she was going to send a letter and talk with the agent, I am assuming she did but my husband did as well and the agent straightened it out that day.

I hope yours works out to be covered that way as well.

This might be redundant and very possible I don't know at all the right answer here. Possibly it isn't covered under the pharma coverage because you must be infused in a hospital/ infusion center setting where Humira you can do at home yourself? I would guess it would get processed under the medical portion as well just because I know when my DD had Remicade BCBSM it was covered and when I got the paid in full bill it was listed as a normal hospital charge, listed with everything else like her room, doctors, anesthesia, psych, Remicade infusion center. Granted it was a monthly bill and a portion she was an inpatient but she did get one infusion outpatient it was listed with the rest.

So did you ever get it straightened out?

I also have BCBS here in Wyoming (from State of California retiree benefit). I was also told at first that it would not be covered...then I got just the right person on the insurance end. We connected and finally understood each other at which point she told me that my Remi would be covered as a specialty drug via my CVS Specialty Drug Pharmacy.

Once that was straightened out the next HUGE hurdle was to find someone to do the infusion and accept the drug as a mail order from my specialty pharmacy. No one here in town or the surrounding area would help me. Sooooo, I have to drive 120 miles one way every 6 weeks to have the infusion at the hospital in Billings, MT. I have the infusion done at the hospital infusion center. CVS mails the Remi to the hospital pharmacy who mixes it for my infusion. I pay my co-pay for the drug plus my portion of the infusion cost. I meet my deductible within 3-4 mos and then only pay the copay for the drug plus my 20% of the infusion price.

My copay did change when I went from 8 weeks to 6 weeks because I was now considered "non formulary". I'm now going from 5ml/kg to 10 so I'm not sure what that will do to my cost. The next step after that is 4 weeks instead of 6.

Hope it all worked out for you.

i sorta got it covered. it is covered under the medical (not pharamcy) but it has to be determined medical nesscary. i am actually going for my 2nd one tomorrow so i hope tgey decided tgey will. i couldnt waut for the ins...i needed the med! and weird...i dont have to get my med...tge infusion place does it.

Fosterfamily2303, we have gone up in schedule and dose a couple of times and it has never been an issue on BCBSIL covering it.

Ours could've also been covered under pharmacy but would have cost more. I think with the help of Remistart we pay 240.00 a year for Remicade.

This thread has been so interesting. It amazes me that so many of have BCBS and yet our meds are paid for in so many different ways

This just supports my thoughts when I first was diagnosed with this crap (yes, pun intended) over 30 years ago. We, as the patient, need to be our own advocate because no one else will, or can, be. Every one of us with our disease, insurance, personal life, etc is so different and everything affects each of us so differently. This is why I love this forum for the support we get from each other and ideas we can give each other. You never know, what suggestions you give could really help.

Thanks all, I've learned a lot from this thread.

Fosterfamily2303 said:

Doc is almost ready to start the remicade. I went and checked with my ins and they said it's not covered. Have you experienced this?? Now what

Click to expand...

Im on Remicade & I went through Johnson and Johnson & they paid 100% of my infusions. I live in Kentucky & just got my disability and medical card. Not sure if they will pay now. Check around on companies they can help you with the costs of meds. Hope this helps

jkd1111 said:

This thread has been so interesting. It amazes me that so many of have BCBS and yet our meds are paid for in so many different ways

This just supports my thoughts when I first was diagnosed with this crap (yes, pun intended) over 30 years ago. We, as the patient, need to be our own advocate because no one else will, or can, be. Every one of us with our disease, insurance, personal life, etc is so different and everything affects each of us so differently. This is why I love this forum for the support we get from each other and ideas we can give each other. You never know, what suggestions you give could really help.

Thanks all, I've learned a lot from this thread.

Click to expand...

i know right! i called ins amd they jut said not covered because the 800 number people didnt know to look under medical. Thank god for this site...i would have not known and not done the infusion. I do hate though how an ins company can decided if sonething is medicap Ness or not . i had he pill cam done and they decided it was not medical mess. and declined it...so Im stuck wih a $1200 bill. Now if my doc didnt think it was not Ness. would she have done it? lol.

i wounder which is better..Johnson & Johnson or Remistart??

i just looked on Johnson & Johnson and family of 2 (we have 3) who income is $62,000 or less qualifya. woo hoo i quilfy for the program. i wounder how thy decide how much they help?

That is awesome!!! I will check it out as well. I have a huge fear that I will lose my insurance in the upcoming year and if so this will come in handy. Cause if they take me off Remi, well....we all know what happens when we have to go our respective drugs. Thanks for the info. I didn't even know about Johnson&Johnson. Cheers!

I thought Johnson and Johnson applied only if you didn't have coverage, where as Remistart is regardless of coverage and income.