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INSURANCE PROBLEM.......

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Crohn's Disease
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Posted 10/7/2010 2:10 AM (GMT 0)
 

i am trying to get my first Rx for Remicade approved by the insurance company.  They are now asking the dr what other conventional methods were tried first? there have been none. im doing the top down approach per the advice of my GI due to the severity of inflammation in the stomach.  with no other methods being tried first, im afraid that they may not approve this for whatever reason.  anyone have any issues going thru this their first time? thanks.

Posted 10/7/2010 4:03 AM (GMT 0)
I have not personally had that problem but I do know others here that have had insurance issues. You are the first I have heard from that had an insurance company that wanted the patient to try other medications first.

My insurance company balked when my GI wanted to increase my Remicade dosage above the "normal" dosing listed by the company. He fought with them, presenting evidence of the medication no longer being effective. and got it approved. Hopefully your GI will be able to convince your insurance company of the need for you to have the Remicade. Let us know how this works out!
Posted 10/7/2010 4:48 AM (GMT 0)
they denied me the 1st time too until my GI wrote them regarding the treatments i had tried and were not working. i think this is pretty standard due to the cost of the Remicade...my infusions are billed at $20,000 a pop right now...ins pays about $10,000 so of course they try to avoid if possible...
Posted 10/7/2010 8:07 AM (GMT 0)
It is pretty common for insurance companies to to try and force other meds before trying Remicade. There is a new law going into effect that will hopefully put an end to that practice or atleast make it harder on the insurance companies to try and pull this crap. If your doctor is adament and forces the issue, you should be able get approved. I was approved for Remicade pretty much off the bat but my previous insurance company, United Healthcare, did try to do what yours is doing. That was about 7 years ago though and not much was known about the medication. Make sure that you get signed up into the access 1 remistart program to help with your copayment. They will pay a large portion of what your insurance company will not.
Posted 10/8/2010 1:41 AM (GMT 0)
ok thx. what is this access 1 remistart program??
Posted 10/8/2010 5:03 AM (GMT 0)
The remistart program is a copayment assistance program for those that are on remicade. Remicade is not a cheap medication and even your copayment can be high. The makers of remicade have a department called access one that will cover a huge portion of your copayment. Cimzia also has one if you ever go on it.
Posted 10/8/2010 5:16 PM (GMT 0)
Remicade is the first Crohn's med I ever took and I don't know of insurance having any problem with it...the GI started me on it right away after dx.  That being said, my current GI says all kinds of things are hard to get covered now that I had done years ago without any problems...Promethius tests, capsule endscopies, etc.  But, my GI also says he can't get Humira approved weekly and I know tons of people get it weekly.  So, I think it depends on the insurance company and what wording the dr uses (and how willing the dr is to fight on your behalf).  I'm getting a little fed up with hearing that things I ask for probably won't be covered, so he doesn't even try.  

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