In short: yes, the insurance can do that. A lot of times the
newer med will only be approved for coverage by the Plan if a different med has
been tried and failed. Unless they are denying the coverage as not medically
necessary (meaning that they do not feel the treatment is necessary for the
condition present, like if a doctor tried to give Remicade for acne or
something) or they have denied the med/service as Experimental/Investigational
(meaning that it MAY be a helpful tx for the condition, but is not FDA approved
for that condition, even off-label approved, and there is insufficient data to
prove the med/service might be helpful), then they are likely denying vedo as
not covered at this time. That means that there is probably an exclusion in
your Evidence of Coverage (health plan contract), which states something like
only the most cost effective reasonable treatment will be covered. Since
Remicade has been around a lot longer, it is most likely to be cheaper than
Vedo, and means the Health Plan has to spend less. Additionally, it’s often
easier to get and the Plan has better price negotiation power.
So, what does this mean for you? In some states (USA), the
State gov will provide an outside appeals option. Look this up for your state,
it would be through your state’s dept of Insurance. Additionally, almost all
plans have an appeal/grievance process. This info should be detailed on the
denial letter you got. Call your Plan and ask for an appeal. Call your doctor
and tell them about the denial and ask them to contact the plan and provide
justification. A letter from your doctor providing justification would be best
for you to have, esp if you have to go to a third party appeals/review process.
The insurance’s goal is to save money, but they also have an obligation to
provide coverage for appropriate treatment. In this case, if Vedo is most
appropriate, you may need to fight. Sometimes, however, the FDA has blocked
providing certain drugs prior to trying others. The Health Plan may be denying
coverage because the FDA hasn’t approved Vedo except for people who have failed
other biologics. If this is the case, no amount of fighting will get the drug
approved until the conditions are met. (This would probably also mean that no
doctor could legally provide you with Vedo without trying something else first
and failing it, even if you were a cash paying patient as the FDA has not
approved the treatment as first line.)
All that being said- on a personal level, I would definitely
try Remicade before Vedo. If Remi didn’t work, I would then try another
anti-TNF before jumping to the other kind (can’t remember what Tysabri and Vedo
are called). I haven’t seen any other thread where you have posted why the doc
wants to start with Vedo over Remi, but since Remi is the standard tx, I would
start with that. There are definite benefits to being on a med that’s been
around a while, it’s more readily available, cheaper (not just for the health
plan, but everyone), more providers are familiar with it and know how to deal
with complications and issues, and there is more long-term effectiveness, side
effect, interaction, and other data. These are all valid reasons to choose Remi
as a first line biologic.
I wanted to add that Remi worked amazingly for me (I felt better not long after my first infusion) until I developed an allergy. Humira then had no effect, but then Cimzia worked for several years. I am now having good response- full remission- with Simponi. I would highly suggest that all the Anti-TNFs are tried. Just because one doesn't work, doesn't mean that none will. It doesn't seem to be all or nothing.