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Remicade Insurance Authorization Question

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Posted 4/2/2016 4:25 PM (GMT 0)
Hey everyone,

So I saw the doctor on Tuesday, we decided on Remicade + azathioprine. She said her assistant would contact the insurance company for authorization. I called the office on Wednesday, to find out how long the authorization process takes, to get some info on scheduling the infusions...left a voicemail, no call back. They've been pretty good so far with getting back to me, so I gave them the usual 1 business day, but I called again early on Friday, and still no response.

Now I'm starting to get annoyed, cause I reallllly was hoping to start Remicade early this coming week (I changed my work schedule so I work the end of the week/weekend and have the beginning of the week for doctors appointments). If I don't hear from them soon I'll have to wait another week (and the doctor had me start my pred taper!) I understand if I have to wait for the authorization because that's something I can't control, but at least I want some information from the person who is communicating with the insurance company!!

I actually spoke to an insurance rep a few weeks ago when I called to ask if Remicade would be covered. She told me that the doctor's office needs to get it authorized, so I said, how long does that take, like a week? And she didn't seem to think it would take that long...

So my question is, for people on Remicade, or I guess any drug that requires authorization, about how long did it take you to get authorized? I'm sure this varies widely based on insurance, drug, etc. but any info on how this process works would be great. Is it like a back and forth thing between the offices, could it take time because of that? Anyone have a similar situation like this? Do you think the doctor's office dropped the ball here? Or am I being too impatient...I want to call them Monday morning, I don't wanna be a pain in the ass, but I just wanna get this started and hopefully get better!!
Posted 4/2/2016 5:16 PM (GMT 0)
All different. I am guessing your GI's office is skilled at getting authorization. Confirming they sent the letter is one step, and then confirming receipt by the insurance co is another. Might get it to the right desk for approvals. A few weeks is normal unfortunately. Hang in there, and keep being a squeaky wheel. Get names of who you speak to and when and write everything down- this broadly applies to all of your treatments and symptoms. It may come in handy.
Posted 4/2/2016 5:38 PM (GMT 0)
If you're not getting a response then call and ask to speak to the office manager.

Depending on the process you could still get it approved this week, usually it take 24-48 hours if it goes smoothly.

I always liked to get my infusions on Fridays because I would make tired and I needed to sleep it off after the infusion.
Posted 4/2/2016 6:10 PM (GMT 0)
Most policies have timelines the company has to meet for certain assurances. In my case, the company has a maximum of 30 days to approve. If your insurance is through your job, someone in your HR department should be able to tell you this, or give you a number to call to ask the insurance company. I suspect it's unrealistic to expect approval in a week. Because of the cost of the treatment, most docs and infusion centers won't proceed until they get the written response, which takes longer than a simple verbal approval.

Your doctor's office should be experienced at getting these approvals. I can just about guarantee that if they forget to dot an i on the request, the insurance company will deny the request.
Posted 4/2/2016 6:14 PM (GMT 0)
It takes several weeks to get insurance approval. It's a medication that requires preauthorization before it can be prescribed. There's a lot of back and forth between the dr and insurance, questions to prove you need the medication, proof other lesser medications have been tried and failed. Insurance reluctantly agrees (after trying to weasel out if they can).

In the mean time, you got to have a tb test and often a chest xray done. You can't have any signs of any active or past signs of a tuberculosis infection.

It's also helpful to signup for the remistart patient copay assistance program. Remistart pays for any copays you are required to pay for the medication only, less $5. You still have to pay any copays for the nurse or the IV which is the smaller portion by far.
Posted 4/3/2016 3:58 AM (GMT 0)
It took a couple of months for me to get biologic infusions approved.
Posted 4/3/2016 4:48 AM (GMT 0)
I was approved quickly the first time I started remicade which was 2009. I had a 3 month hiatus to try humira and then returned to remicade which was 2014. The infusion nurse for my then GI doc filled out a form that was either "urgent" or along those lines and I was approved that day. I think several weeks to months seems in poor form but I realize the insurance companies have a lot more power these days. In 2009, I skipped from mesalamines to a biologic without a problem. If I were requesting remicade now for the first time, my insurance would require humira trial with failure first. Good luck and keep calling the office until your questions are answered to your satisfaction. You could also call your insurance company and ask for the status of your remicade approval.
Posted 4/3/2016 8:15 PM (GMT 0)
Thank you everyone :)

katmom- yeah this medical group seems like they probably do this routinely--they even have their own infusion center. didn't realize it could be a few weeks from my convos with insurance reps & doctors so far :/ i'll keep being a squeaky wheel though. :)

ks1905- that's a good idea. i always hit the extension to go directly to my doctor's office but i should try the general number too and see if there's someone above that assistant who could check this out for me. i'm crossing my fingers that i might hear some good news monday.
right now, i'm scheduled to work the end of the week/weekend at my job, so i was hoping to do the infusions on mondays, have my iron on tuesdays, and that's like having my "weekend" to recover, haha. at least for now, before i know how it will affect me. but at this point i'd go pretty much any day they'll have me just to get it (i'd rather not miss work tho as they don't seem like theyre willing to cut me much more slack for this >_>) Fridays are a good idea--i'm hoping to get an office job soon so that schedule would work nicely.

jujub- i'm not eligible for insurance through my job but luckily am still eligible through one of my parents. like i said the insurance rep acted like it wouldn't even take a week. but maybe she didn't know, or was just saying that. so i guess it does involve more back and forth than i thought :/

ipoop- that's what i was worried about--the back and forth and insurance not wanting to cover it. like i said the rep made it sound so simple. i had my tb test run through my blood test a month ago, the doctor went through my results this past week and i had my hep B and pneumonia vaccines. so i'm all set there! i looked up remistart so i guess i'll work on that paperwork in the meantime, lol :)

casey_LB- sorry to hear that :/ i'm really hoping that it won't take that long but i guess that is more common than i realized.

platinumpixie- wow, approved the same day, that's great! in my research i found my insurance company policy last year was to require failure of 2 out of 3 of: 5ASA, steroids, immunosuppressants. but again, when i spoke to the rep, they said as of this year the policy is just to request authorization. i guess that is probably taken into account in the authorization request though. thanks--i'll definitely be calling the office again tomorrow. and now the insurance company as well.
Posted 4/3/2016 10:22 PM (GMT 0)
justgettin...don't give up!! I recently had SO much aggravation and STRESS trying to get my Remicade. Fortunately, my gastro. doc had a new person working for him, who knew how to deal with insurance comanies. For over 15 years, I'd had no problems. I was told that, as of Jan. of this year(2016)the Obamacare came into play in all its' glory. What a crock..Seems that the tiers?sp were changed; Remicade was put into a different tier. SO, my insurance denied it. With lots of emails, phone calls, and letters, the gastro docs' representative got approval for another year, from my work insurance (now retired). Be patient and NEVER...NEVER..give up. If you lose your insurance in the future, Remistart may help you. But...if, like me, you have insurance, and any part is paid for by Tricare or Medicare..they're probably going to deny it. Just don't give up. Remicade is the only drug I've found, that gives me remission. Thank God for the remission, but I wish the drug companies would lower the cost! Good luck and hopefully...you shall be in remission QUICKLY
Posted 4/3/2016 11:01 PM (GMT 0)

gizmo said...
For over 15 years, I'd had no problems. I was told that, as of Jan. of this year(2016)the Obamacare came into play in all its' glory. What a crock..Seems that the tiers?sp were changed; Remicade was put into a different tier.

Thank God for the remission, but I wish the drug companies would lower the cost! Good luck and hopefully...you shall be in remission QUICKLY

There should be a biosimilar (generic) version of Remicade approved next year so there will be a lower cost alternative for Remicade, this was part of Obamacare healthcare reform bill.
Posted 4/3/2016 11:09 PM (GMT 0)

jujub said...
Most policies have timelines the company has to meet for certain assurances. In my case, the company has a maximum of 30 days to approve. If your insurance is through your job, someone in your HR department should be able to tell you this, or give you a number to call to ask the insurance company. I suspect it's unrealistic to expect approval in a week. Because of the cost of the treatment, most docs and infusion centers won't proceed until they get the written response, which takes longer than a simple verbal approval.

Your doctor's office should be experienced at getting these approvals. I can just about guarantee that if they forget to dot an i on the request, the insurance company will deny the request.

I had an appointment with my GI on a Thursday and I was getting my first infusion the following Friday, I could have had it sooner but the appointment nurse suggested Friday because I was getting my infusion at the Oncology Infusion center at the Hospital and she said most cancer patients didn't get infusions on Friday so it was less busy. This was 2008 so things could have changed since then.

I got an off-lable approval last year for Cimzia and it took less than 2 weeks.
Posted 4/4/2016 12:13 AM (GMT 0)
KS...THAT would be GREAT. I'll be watching and reading...and hoping. Be safe and thanks for the info.
Posted 4/4/2016 5:16 PM (GMT 0)
thanks gizmo, i've looked into remistart to help with the copays as well as other organizations that would help if not covered under insurance. i'm glad to hear remicade is working for you, and that you saw through the hassle they put you through!

ks1905-generic remicade! sounds like good news.
also, i'll be sure to ask about which days are busy at the center. when i go for my iron IV's (usually tuesdays, but i've been there on fridays and mondays too) the mondays and tuesdays seemed the busiest, so that may be just a general trend across the board.
Posted 4/4/2016 5:34 PM (GMT 0)
Update:

-called the insurance company today. They said they didn't have a request in their system for Remicade. they also said it can take 15 days to process.

-called the doctor's office, left a voicemail saying that i need info since i've called now 3x about this.

-got a call back 2 hours later. The assistant told me that they began the paperwork before that appointment, back on 3.22. she reallyyy pissed me off though. she's really condescending, and was sketchy about giving me the date that they began the process. I had to ask the question like 3 times before she told me the date of 3.22...she just kept saying stuff like, it's a process, we're all working on it.

and then when i heard the date i said, okay, so that just means i'm waiting on the insurance company. I didn't mean literally, i'm waiting on them, i just meant it more like, now i know that it's in their hands. And she has the nerve to say, slowly, as if i'm a child, "remicade is a really expensive drug". Seriously??? As if I didn't know that. (this isn't the first time she's spoken to me as if i'm incompetent...she makes me dread calling to ask a question. if the doctor wasn't so great, i'd be looking for a different office...)

finally she gave me a little more clarification, she said she had an email from (i don't remember exactly the name...i was pretty angry then at being spoken to like that but still trying to be polite) some part of the insurance company requesting more info from her on friday. So she said I should be hearing from her midweek.

Which is basically, all I wanted to know, just an idea of how long I can expect to be waiting...I've felt so lost these past few days, not knowing if i could get this drug in a few days or a few weeks... I still don't know exactly (and i don't know why the insurance and office would tell me 2 different things) but at least i've heard from someone (please excuse my rant about that, lol) and know that this process is happening!
Posted 4/4/2016 5:59 PM (GMT 0)
Sounds frustrating. At least you now know both your doctor's office and insurance are communicating. The time to approval varies greatly, insurer-to-insurer. If your doctor's office provided enough clear evidence of your medicinal need and insurance has only a few questions or request for more information, then perhaps approval will be shorter. All you can do is wait. It's usually approved when they're ready to.
Posted 4/4/2016 6:05 PM (GMT 0)
Yeah i feel more assured now that I know the process is at least begun, before I had no idea if anyone even submitted the request, or if they had and gotten approval and just didn't bother to tell me. So at least I feel better about the waiting now :)
Posted 4/4/2016 7:01 PM (GMT 0)
I recently was told by my pharmacist that pharmaceutical company assistance programs such as Remistart usually can't be used with any sort of government insurance (Medicare, Tricare, Medicaid, etc.). Apparently signing the agreement with the company would be seen as the government favoring one business over others. I don't totally understand that reasoning, but then, it is the government.
Posted 4/6/2016 2:09 AM (GMT 0)
The FDA approved the Generic version of Remicade today.

www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm494227.htm
Posted 4/7/2016 3:00 AM (GMT 0)
jujub- Yeah I saw that on the form and wondered why that was the case. Interesting. They also won't help if you don't have any insurance, but I did find in my research that there are other programs to go through for those instances. I've been learning so much about navigating all this healthcare stuff lately--still havent figured it all out, lol.

ks1905- thanks! wonder what impact this will have.
Posted 4/13/2016 7:12 PM (GMT 0)
Update:

My pre-certification is still "pending"... *sigh*

Luckily I'm doing well on the pred (tapering) + aza. And the communication with the doctor's office has improved. So I'm not feeling as anxious about this.

The only news is that I will have to do this in a hospital setting instead of the doctor's office, because I do not have a prescription plan. So that way the infusions will be covered under medical insurance. That might be what's taking the insurance so long to approve, who knows.

But I was told that once I am improved, I may need to wait for an appointment at the hospital too...

As soon as I get a better job (with benefits), I'm signing up for a presciption plan!! Have a feeling it might have made this easier...
Posted 4/14/2016 12:15 AM (GMT 0)
Nope...they're all slow. LOL I'm glad you did get approved. I KNOW how frustrating it can be...just trying to get a drug that will help you. Try to be patient...well...SUPER patient. These days, it seems that nobody really cares, unless it is they who are having a problem. This is a great support group. I've been reading the older posts and have learned more by reading this groups' posts, than my doctors ever told me. Seems that our health is in OUR hands. Be safe and best of luck to you. NEVER give up!!!
Posted 4/14/2016 2:20 PM (GMT 0)
Thanks :) And yeah, this website has been an amazing resource for me. Not just with the factual stuff, learning about symptoms, meds, alternative treatments, but with just not feeling alone. As much as people who don't have UC try to understand (and I give them a lot of credit for trying), there's nothing like talking to/venting with people who experience the same and similar things as you do!
Posted 4/15/2016 8:00 PM (GMT 0)
Don't do what I did! Before my first Remicade infusion I contacted my insurance company to get approval. The insurance company approved me with the stipulation that they would supply the infusion clinic with a vial of Remicade. So I scheduled my first infusion and the infusion clinic contacted me and said they had not received my Remicade (from the insurance company). The infusion clinic said I could still keep my appointment and that when they received my Remicade they would replace their stock.

So, I called the insurance company to as when they would send the Remicade. I told them that I was still scheduled for my infusion and that the clinic would replace their stock with the Remicade sent to them. The insurance rep told me that I would have to pay $3400 for the infusion and that the clinic could not use the sent Remicade to replace their stock!

I just about had a heart attack. I would be out $3400 because they didn't send the Remicade on time? I think I had another loading dose scheduled in a couple of weeks that would presumably cost another $3400.

Long story short, the nurse at the infusion clinic straightened the whole thing out. Thank God. Mary
Posted 4/16/2016 12:08 PM (GMT 0)
My infusion center has done that before, used an in stock remicade vial because my mail order pharmacy couldn't ship theirs in time. She then replaced the missing stock with my mail order, when it did arrive. Never told the insurance company, wow now I never will knowing they'd flipout... I think it's common practice on the using one in-stock and billing like it arrived on time.
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