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Ugh! insurance denying remicade after 2 years

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Ulcerative Colitis
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Posted 9/18/2017 9:16 PM (GMT 0)
I just moved from Ohio to Pennsylvania. I've been on remicade for 2 years. After a severe flare 2 years ago I received "rescue remicade" when in the hospital. I had to wait for 2 weeks in the hospital to get approval for the drug.

Now my insurance company is denying the drug because it's considered experimental for uc in Pennsylvania. . If I had crohns it would be approved. My doctor is calling tomorrow to do a peer to peer request for approval. If insurance doesn't approve, pharmacy won't fill the prescription so no infusion.

I'm currently at 6 week intervals and today marks 6 weeks. I'm showing my usual symptoms that happen when I'm late with my infusions. I'm trying not to panic but worried that the drug that finally worked will be denied.

Anyone else ever run into this problem?
Posted 9/18/2017 9:25 PM (GMT 0)
Sorry I can't offer any help, but I have to say that is just ridiculous. It's bad enough that we have to deal with all this crap to begin with, but bs insurance problems just make it that much worse. Hope your doctor gets them to see sense/be reasonable.
Posted 9/18/2017 9:56 PM (GMT 0)
I am surprised some insurance plans still have it as experimental for UC.

Did you have to change insurance companies when you moved, or same ins. company different state plan? This sounds like the kind of thing that happens with a completely new company.
Posted 9/18/2017 11:09 PM (GMT 0)
Have you tried contacting Janssen CarePath to see if they can help cover your infusion in the interim?
Posted 9/19/2017 12:23 AM (GMT 0)
I'm really sorry to hear about this. I had the same problem around a year ago. I'd been in remission for almost 5 years...until I missed the infusions. My doctor contacted my insurance company and they finally approved me for another year. I'd been getting infusions since before the year 2000. Hopefully, SOMEDAY, the price will decrease. More and more it seems to me, the insurance companies are dictating our medical care, pharmacy, and hospital testing. Keep trying and asking your doctor to keep trying to get you approved. Remicade is not an experimental drug....it's an expensive drug.
Posted 9/19/2017 1:22 AM (GMT 0)
Thanks everyone. I haven't changed insurances, just moved states. Apparently pa has different code under BC/BS. I've been really lucky as my husbands company chose the best plan and we only pay a $200 deductible as a family all year...so my remicade has been free as well as all of my hospital stays, testing, etc. I guess worst case scenario we could pay for a single infusion out of pocket and hope for reimbursement. That would pretty much wipe out our savings!!

I'll see what happens tomorrow after the call me and then try to contact carepath.

Thanks everyone!
Posted 9/19/2017 1:34 AM (GMT 0)
I wouldn't stress over this too much, this is pretty common with biologicals. Most insurance plans require "prior authorization" before approving a script by the insurance company meaning they will reject it until the doctor provides more documentation and sometimes a peer to peer call.

It's not like an antibiotic were they just approve and fill the script the same day.

It's approved by the FDA for UC so it shouldn't be too difficult to get covered, your GI just needs to prove your need for Remicade which shouldn't be too difficult because you were previously using it.
Posted 9/19/2017 1:41 AM (GMT 0)
I'm in PA and I know my GI has many UC patients on remicade. You should be able to get it approved. Sounds like an insurance snafu
Posted 9/19/2017 1:47 AM (GMT 0)
good luck with the appeal. Since BC/BS approves it in other states, that should make it easier. It is not that "pa has different code under BC/BS" - the states have no opinions on formularies, or what is approved. It is that each state insurance comissoner licenses plans in each state, and the BC/BS plan in pa is different. It is the other way around - BC/BC has a different code in PA. This is entirely insurance and the state has no input - they only keep insurance plans from crossing state lines. What the companies offer is all on the companies.

I hope you get it covered.
Posted 9/19/2017 3:20 AM (GMT 0)
That is horrible news. Insurance companies shouldn't have the right to make decisions on which drug is more effective for an individual patient. Hopefully your doctor will straighten out the snafu -- and soon!
Posted 9/19/2017 12:34 PM (GMT 0)
That's simply awful! Here's a billing code guide for Remicade from Jansen. I'd hold their hands and help them with what they should really know how to do themselves. Billing codes are the infusion center or hospitals problem, more so than insurance. If the facility uses the correct coding, then it should be accepted by the insurance, I believe. /www.janssencarepath.com/sites/www.janssencarepath.com/files/remicade-billing-guide.pdf
Posted 9/19/2017 1:07 PM (GMT 0)
Here's the section of highmark bc/bs medical policy they are basing the decision on. Because I only tried one immunosuppressant (prednisone) not 2 they are saying I don't qualify. Peer to peer call is today, so if that fails I'll call myself and battle it out.

Procedure Codes
J1745, Q5102


Infliximab, cA2 (Remicade) or inflixmab-dyyb (Inflectra) may be considered medically necessary for patients who meet EITHER of the following criteria:

Ulcerative colitis - for the reduction of signs and symptoms, maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in patients with moderately to severely active ulcerative colitis who have had an inadequate response to
-Two immunosuppressants (e.g., corticosteroids azathioprine, or 6-mercaptopurine); or
-To induce and maintain clinical remission in adult patients with moderate to severe ulcerative colitis who require continuous steroid therapy

The use of infliximab or inflixmab-dyyb for any other indication is considered experimental/investigational, and therefore, non-covered. Scientific evidence does not support its use for any other indications.
Posted 9/19/2017 1:50 PM (GMT 0)
You're currently on Imuran (also known as Azathioprine) and you've taken Pred and were unable to maintain a steroid-free remission without the Remicade, so I see no problem here. Perhaps your gasteroenteroligist just needs to properly communicate this to your insurance?

The Q-code is weird and could be problematic. I'd instead expect to see pairs of CPT codes like 96413 & 96415 or 96365 & 96366 for infusion of inflixmab/remicade.

J1745 is good.

Make sure they are using the right diagnosis code: K51.00, K51.20, K51.30, K51.50, K51.80, or K51.90 for UC.
Posted 9/19/2017 6:51 PM (GMT 0)
Good news!! My doctor called and had the peer to peer and we are all set to go by Friday! Thanks for the encouragement. Sometimes I just need to hear positivity from others as I tend to panic.
Posted 9/19/2017 7:05 PM (GMT 0)

FlowersGal said...
That is horrible news. Insurance companies shouldn't have the right to make decisions on which drug is more effective for an individual patient. Hopefully your doctor will straighten out the snafu -- and soon!

It's pretty awful, but the insurance company does have a right since they pay. If they pay, they have a right to do whatever. You can still get the drug, they can't deny you the drug, but you'll just have to pay yourself....
Posted 9/19/2017 8:54 PM (GMT 0)
Glad it worked out for you! Last thing we need is more stress and anxiety over getting our darn medication....
Posted 9/20/2017 2:31 AM (GMT 0)
Yay! So happy for you! Whew!

Bull I have to respectfully disagree -- not that I want to get I to an insurance argument -- but we the insured also pay and most of us have paid a LOT over the years. Whatvi object to is office staff reading g codes and regulations and taking those rules over a doctors knowledge and advice. Ive been on the wrong side of some idiotic denials by an insurance company that ended up costing them 3 times as much as it should have.
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