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Remicade Denied...

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Crohn's Disease
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Posted 10/9/2010 12:00 AM (GMT 0)
 

so my dr's assistant told me today that the ins company has denied my claim for remicade because we haven't tried any other methods to treat for the severe inflammation, and that i don't have any fistulas.  i guess my drs office is now trying to go directly to the rx company (caremark/cvs) for approval.  so i don't know where this leaves me. the dr said the reason he wanted to start with the top down approach, is because he didn't feel any of the other meds really worked that well.  does anyone know if there is a generic brand of remicade? im so frustrated right now, and feel like i don't know where to turn. my dr tells me i need this med, but now i cant get it.  theres gotta be a way to get it, if a person needs it....

Posted 10/9/2010 12:36 AM (GMT 0)
You might check if your insurance has what they call a "patient advocate". I think you may get some help there.
Posted 10/9/2010 12:47 AM (GMT 0)
I don't know if they still have this but when I first tried to start Remicade I was denied and the makers of Remicade had a program to help you if you were denied. I don't remember a lot of details because it was 10 yrs ago and I was still on my parents insurance at that time so it was my dad who handled it, but they helped him fight to get it approved and they did approve it.

You should check online and see if they still have anything like that, most high end drugs like Remicade do have some sort of patient assistance.
Posted 10/9/2010 1:04 AM (GMT 0)
There is no generic form of Remicade. Let your doctor's office work from their end. If in your spot, I would dig up my insurance coverage information and thoroughly read it. I know that companies like Aetna will not pay for tests they consider experimental and it is spelled out in their coverage certificates. Read your coverage carefully. If you cannot find where it specifically demands a certain medication protocol for treatment of inflammatory bowel disease, call them and ask to tell you what section describes this protocol. I am very suspicious of the insurance company denial.
Posted 10/9/2010 1:43 AM (GMT 0)
See if your insurance company will approve humira or cimzia.They are all in the tnf inhibitor class and are both cheaper than remicade. I personally prefer remicade but other have even responded better to the other two. Remicade does have a program through access 1 to help those whose insurance won't approve them and to help with copays.
Posted 10/9/2010 2:24 AM (GMT 0)
I don't necessarily have advice for you on how to get approved for Remicade, but I have something to add for you to consider.

I was diagnosed with Crohn's 10 years ago. When I was first diagnosed I was only 17 and had no idea what I was in for. To make matters worse my doctor wasn't very helpful, he gave me a couple pamphlets that described what symptoms you might have and was very general and sent me on my way with my script for Asacol. Here's the kicker, the Asacol worked. I was symptom free for the next 6-8 months. Being that I had no idea of the seriousness of my condition I didn't take very good care of myself I smoked profusely, drank heavily once at college, and drank a ton of coffee. Even so, for the next two years when I had flare-ups the doctor would give me Mesalamine enemas (same drug as Asacol) and my flares would go away.

Moral of the story is that at first Mesalamine, which is considered one of the safest drugs, worked for me. I firmly believe that had I taken care of myself it would have continued to work.

I have taken Mesalamine, Prednisone and Remicade for my Crohn's. The Prednisone really messed me up and the worst thing is I had no idea how bad of a drug it was, I only knew that it stopped a flare dead in its tracks. As far as I was concerned it was my saving grace, until I was hit with the nasty sides.

My advice is that you learn everything you can about Crohn's, strip your diet down to bare bones and don't start reintroducing foods until you are in remission (ask your doctor about doing this if you haven't already and he will help), learn how to deal with stress as best as you can and do everything within your power to minimize it, and most importantly consider starting from the bottom of the ladder; you are really limiting your options if you use the most powerful drugs first.
Posted 10/9/2010 4:37 AM (GMT 0)
I thought infliximab was the generic form of Remicade?
Posted 10/9/2010 4:54 AM (GMT 0)
where would i find out about the remicade assistance program? has anyone used it, or know where to get info on something like that? as far as starting with the top down approach LIVIN, i guess the inflammation is really bad based on the results from the blood test. other than the stricture in the small intestine, i really have no other side effects from crohns. no diarrea or anything like that. i get like these occasional "pokes" in the sides of my stomach a cpl times a day, but other than that, i really have no complaints, and those aren't really even worth complaining about based on what others are experiencing.
Posted 10/9/2010 4:59 AM (GMT 0)
infliximab is just the scientific name of the medication. There is only one remicade and it is made by centicor.(spelling?) Humira came afterwards as a less expensive and easier option that used Human DNA instead of mice dna. Then cimzia followed but they are all very similar.
Posted 10/9/2010 5:05 AM (GMT 0)
i was denied 1st from that same prescription coverage...doc tried again with more info and what else we had tried and i was approved.
Posted 10/9/2010 8:37 PM (GMT 0)
i will keep my fingers crossed and keep everyone updated. where at in Zona are you mtgman?
Posted 10/10/2010 4:49 AM (GMT 0)
i live in cave creek
Posted 10/11/2010 3:55 AM (GMT 0)
I think insurance companies always deny expensive things first =) I know my GI regularly has to send over more information to my insurance company for approvals - he said it's part of the insurance "game."

I hope it gets approved ASAP! I just recently got (re)approved for Cimzia but under a new insurance company and he had to jump through hoops for that, too, even though I had already used Remicade, Humira, 6mp, Prednisone, etc AND had a recent resection AND a follow up scope that showed rapid development of inflammation post-resection. Obviously Cimzia was needed, and the best option, but he still had to prove it to some guy sitting in a cubicle at my insurance company.

Good luck!
Posted 10/11/2010 7:44 PM (GMT 0)
Johnson & Johnson own Remicade in some way, I am not exactly sure of the details, I don't think they own 100% of it, but I dunno.

Centocor is a wholly owned subsidary of Johnson & Johnson.

Merck is also involved.

Remicade did 209 million dollars in sales for 2009.

www.bnet.com/blog/drug-business/maybe-a-merck-drug-swap-with-j-j-could-make-its-remicade-headache-go-away/4257
Posted 10/11/2010 8:25 PM (GMT 0)
I have to agree with Ides. Read your policy or call customer service and ask where specifically it is spelled out what protocol you must follow.

My husband was just denied coverage for compression stockings for DVT's. In dealing with a supervisor at the insurance company, I asked where specifically this would be found in our policy, because we were covered for durable medical equipment which comp. stockings are suppose to be. He told me it wasn't in the policy, but they were not covered. I kept asking, how I was suppose to know what was covered if it wasn't in writing, online or in print. I was not happy, and was going to call the doctor to find out if there was some other option, but needed to calm down first. These things are expensive ($120 a pair and he's suppose to have 4-6 pairs). Before I could calm down, the supervisor called me back to tell me that they were going to cover the stockings, he didn't really say why. But my guess is because it isn't in the policy that they aren't covered, so they have to.

Moral of the story, if it isn't in the policy as an exclusion, you may have grounds to make them cover it.
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