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Please Help with Xeljanz. What Insurance Plan do you have??

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Ulcerative Colitis
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Posted 9/10/2018 8:52 PM (GMT 0)
I began Xeljanz 5 weeks ago and am, for the first time in 2.5 years, beginning to feel more like myself. I have been in a significant flare that has dramatically altered my daily routines and has led me to be hospitalized at one point after losing 55lbs over a period of several months. I had failed numerous medications prior to finally getting Xeljanz approved and now I fear that I will no longer be able to continue the medication after I run out of the remainder of my medication. My spouse is starting a new job and my insurance coverage through her previous employer is terminating. My coverage through her new employer will not begin until the end of the year and even then I am not sure if it will cover Xeljanz. Fortunately, we were just married at the end of July so I am able to enroll in private insurance plans outside of open enrollment due to the recent marriage. Unfortunately I have been unable to find out what plans cover Xeljanz as any plans that I have looked into require you to be a member before they will allow you to review their Preferred Drug Lists to see what medications are covered. This medication is a last resort for me before surgery. I am desperate to find a plan that will cover the medication that has finally provided me relief.

PLEASE HELP. If you are currently taking Xeljanz, or have a friend or loved one who is, what insurance plan are you using? Is the medication on the formulary, require a PA, etc?

Thank you so much in advance for your help!

, Ian
Posted 9/10/2018 9:04 PM (GMT 0)
Ian,

It's just going to be a fight because it is not on their yearly formularies because it was recently approved by the FDA for UC in June.

You've got a good case that should be winnable with a good insurance plan. You have two things going for you, currently have the medicine and you are responding to it.

This will take a little bit of effort by your GI's office but it is definitely something that you should be able to win; it make take two appeals and your GI making a phone call.

Xeljanz is not that expensive compared to other medications. I was given Stelara prior to it being approved for CD. They did it as an offlable approval since it was not approved for CD at the time. My insurance company is billed $43K a dose.....again, Xeljanz is already approved by the FDA.

Ask your GI's office for guidance about insurance policies and Xeljanz.
Posted 9/10/2018 9:27 PM (GMT 0)
I recently got a formulary exception for Uceris foam. The office told me they had tried and been rejected. I contacted the insurance myself by email. I wanted the request in writing so did not use the suggested phone number.

I made a list of all failed medications with dosage. This took awhile so the MD office may not have time to go into all that detail. Medication had been prescribed and was already at the pharmacy. It was still expensive but there were significant savings, at least for the first fill. (The next time I picked it up is another story.)

This may not apply to you, or your insurance or your medication. I have Medicare part D. But it's worth trying again on your own for any formulary exception.
Posted 9/11/2018 12:17 AM (GMT 0)

naturalcurl said...
I recently got a formulary exception for Uceris foam. The office told me they had tried and been rejected. I contacted the insurance myself by email. I wanted the request in writing so did not use the suggested phone number.

I made a list of all failed medications with dosage. This took awhile so the MD office may not have time to go into all that detail. Medication had been prescribed and was already at the pharmacy. It was still expensive but there were significant savings, at least for the first fill. (The next time I picked it up is another story.)

This may not apply to you, or your insurance or your medication. I have Medicare part D. But it's worth trying again on your own for any formulary exception.

Your GI’s office should handle this. It’s not your responsibility and your not as capable of handling this like your GIs office who is probably doing this everyday.

My GI’s office has a staff member and all she does is coordinate insurance approvals for biologicals and non-formulary meds.
Posted 9/11/2018 12:44 AM (GMT 0)
Got it approved on spot when GI made the call to insurance. No hassles and gave refills for 11 months.
Posted 9/11/2018 12:59 AM (GMT 0)
I have Aetna POS (like PPO)
I took Xeljanz earlier this year as a last ditch effort to avoid surgery. I had failed a number of meds (humira remicade, enttvio you name it!) Initially Aetna denied it but approved it on appeal. I was approved for 5mg 2x a day. I tried it for about 2.5 months but it didn’t help. I often wonder if 10mg 2x a day would have made the difference.
I ended up having 2step jpouch surgery last month.
Best of luck to you. 😊
Posted 9/11/2018 3:32 AM (GMT 0)
Hello Ian I'm currently trying to get approval with united healthcare. I kept my insurance via cobra because I quit my job earlier. I had already met my deductible and didn't want to lose it.
Posted 9/11/2018 4:39 AM (GMT 0)
I wouldn’t worry, if it isn’t covered you can get it covered. It’s not that expensive from the insurers perspective, I work in drug coverage and I think you’ll be fine. There should be ways around the gap you have with no coverage. For instance, if you fill a 30 day supply, you can refill it after about 25 days. Ask the pharmacy around day 23 if it’ll go through yet if you want. So if you always fill a few days early you’ll have some pills to cover you if needed. If your doctors office has samples that can help. Also, when you get the new plan, xeljanz has a copay assistance card which will reduce your out of pocket cost but you still get to count the savings to your deductible.

Glad to hear it’s working for you, my dr has mentioned it to me as a possible thing to try next.
Posted 9/11/2018 11:53 AM (GMT 0)
Husband has been on Xeljanz for over two years. First started before it was approved by FDA. We have had to go through the appeal process with our insurance every year the prescription was renewed, but always got it approved. It should be easier for you now that Xeljanz was approved by FDA for UC, but insurance companies are very slow to add costly meds to the list (probably intentionally). Your doctor's office needs to be very pro-active. Also, once you are on a new employer-sponsored plan, sometimes the HR benefits people can be helpful.

This should be covered by most plans, since for some it is the only option outside of surgery.

You could also try to call Pfizer directly to see if they have any patient assistance programs.

We have a very good plan with Blue Cross/Blue Shield provided by my employer.
Posted 9/16/2018 7:19 AM (GMT 0)
It is on the Kaiser formulary list for my area (their formulary list is public for each area if they are near you)
Posted 9/23/2018 2:57 PM (GMT 0)
Sorry I have no info to offer at this time. I am in the process of maybe being changing over from Remicade to the drug Xeljanz due to a secondary skin condition thought to be caused by Remicade. I will know more after my next and maybe last Remicade infusion this Friday. If I find out anything useful while going thru this process of trying to get coverage I will update you with a post on this tread.

Please keep us updated on how it goes, and how you are doing. I am happy to support you in anyway that I can.
Posted 9/23/2018 4:03 PM (GMT 0)

ks1905 said...
...Your GI’s office should handle this. It’s not your responsibility and your not as capable of handling this like your GIs office who is probably doing this everyday...

It is a service provided by many medical offices. They do not have to do it, and some offices are starting a $25 fee for each letter, phone call, or document produced. Just saying.

Ultimately, until we get a better system, insurance is how we arrange to cover costs of our care. The final responsibility for appeals and wrangling with companies is on the consumer. Medical offices can do it more accurately and certainly would be doing it more often. We should just expect to see this becoming a fee for service item. Heck, even getting medical records sent from my doctor's old office to her new one was charged a fee.

Anyway, the manufacturer might have some information on plans (or pharmacy benefit networks) more likely to cover in particular states Since it is newly approved, it is most likely going to be an appeal for the next year or so.

I've used COBRA between jobs. It can be pricey, but worth it if you have meds that would be out of reach without coverage.

good luck
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