Entyvio insurance question

That seems a little weird that you would not need a prior authorization. I've had two insurance companies require a prior auth for Entyvio. Sometimes reps are not that well trained on newer meds and may have given you incorrect information. Just make sure all the necessary approvals are in place before showing up to the infusion center...I got turned away because my doctor's office messed up the insurance approvals.

Nix,

If it is on your insurance's pharmacy formulary then it is already approved but if it's not on the formulary then you need preauthorization. But it's always good to call your insurance for something like this. Like with Humira it was approved on my formulary but I had to have a hep-c test first for the insurance company to approve it fully. They also made me go through their mail order pharmacy for it...ugh; that's a whole other topic.

I'd also call Entyvio to see if they can help you with your co-pay. I always got assistance with my copays from Remicade, Humira and Simponi.

I would be very, very careful if I were you. I got a pre-authorization letter sent BY THE HOSPITAL in behalf of the insurance company for 8 infusions. I had my first infusion and they billed me $4900. I wrote a letter and included my pre-auth letter, the bill was still there and now a new one for another $4900. The billing department was not returning calls. Then they billed me again for now a total of $13000.

I contacted the patient advocate that is assigned by the hospital, she cleared it up, but then they billed me for the latest one of $4900. The billing department told me that even with the pre-auth letter if the insurance company doesn't pay the patient is ultimately responsible for the bill. Then either you go to collections (not recommended) or go to court which takes forever.

Make sure you have the pre-auth letter in your hand, if possible get a letter from the insurance company itself.

$30,000 a year, every year, is a lot of money for the insurance company to pay.

Whew, that's great! Fingers crossed for you. My process went something like:

1 Get authorization sent from doc to Insurance
2 Confirm authorization was received by Insurance
3 Get approval notice
4 Wait 72 hours for approval to get into Insurance's system
5 Wait another day for prescription to be transferred to Insurance's mail order pharmacy
6 Get a quote for a copay and then be told how to contact Entyvio's assistance program
7 Call Entyvio's assistance program, get instructions
8 Fill out assistance form, email to doctor to complete
9 Have doctor fax assistance form to Entyvio program
10 Wait a day for assistance to get into system
11 Call mail order pharmacy and arrange for delivery of medication

I think I'm even missing something...it was exhausting!

Even though my insurance company said it was covered without "pre-approval" (I got that in writing from my company's insurance broker), we have had a go around with each infusion. Ultimately it has been paid, but it has taken many hours of phone calls and follow up between me, the specialty pharmacy and the insurance company. Last month, to my surprise, I just got a letter from CVS/Carefirst saying we were "pre-approved" for a year. Because it is a new medication there seems to be some confusion in connection with the billing.

Good luck.

(Unfortunately for us, after six infusions, it does not seem to be working for husband with severe UC. Only side effect super extreme exhaustion.)