Waiting to Start Remicade

Hi everyone! My 14 year old son was just diagnosed with Crohns a couple of weeks ago. We are waiting for the insurance company to approve the Remicade. We found out it was denied a couple of days ago and now our GI doc will do a peer-to-peer review with the insurance company to get them to approve the treatment. I don't know how much longer it will take.

I was wondering what your experience was in the beginning waiting to get the first dose for your child. My son is quite anxious because he had fistula surgery a few weeks ago and has a seton in place. The fistulas haven't fully healed and they are still draining. The doc has indicated that after the first treatment, the fistulas should disappear. My son is now experiencing some mouth ulcers too.

Anyway, we are frustrated with the process and nervous that insurance will reject it. And we have great insurance! That is why I'm surprised. Thoughts, advice?

Hi fcbeach,

You will get a lot of useful information from folks in this group, but here's my thoughts:

1. Usually the GI's office and insurance company can figure out the Remicade approval even if its not on the first try. It takes less than a month. Your insurance contract will have exact details on the time limits on the process. For us, it took about 20 days to get approval.

2. If for some reason you are not approved after the peer review, you can appeal with the state insurance commission. Unless you live in a patient unfriendly state, they will side with you and your doctor, especially since a child's health is involved. You can also approach the Remicade foundation (1-888-ACCESS-1) to assist in situations where you have commercial insurance but the insurers does not agree with your doctor. Also take a look at the foundations listed here: http://www.janssenprescriptionassistance.com/remicade-cost-assistance

3. In terms of wait, I would go by your doctor's advice. Biologics do not provide as immediate a relief as steroids do. But they do work over longer term in a lot of people. Only you and your doctor can judge whether you wait for 2 weeks or 4 weeks for the insurance situation to resolve itself, but I wouldn't go beyond, say, 30-45 days. If you can manage to negotiate a self pay discount with your doctor's office, you may not have too much out of pocket till the situation is resolved. Remicade is expensive, but not as expensive as some other biologics and is going off patent next year.

Hope your son feels better soon!

Sorry, no advice as my son was already inpatient for an abscess and fistula when he was started on Remicade. I suppose that could be one way around insurance, being admitted?