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Getting Xeljanz approved by Insurance

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Ulcerative Colitis
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Posted 11/19/2018 5:00 PM (GMT 0)
Has anyone else had a ridiculous time getting Xeljanz approved by insurance? I have been trying since September 1st and what I have experienced is actually comical at this point. I was denied at first.... pharmacy filed an appeal. Appeal was finally heard around mid October and I was approved for 20 mgs... however my doctor wrote a prescription for 5 mg pills and they will not allow more than 2 pills a day...Tried for 10mgs 2 x a day.. that was denied as well. Appealed that.. back to the drawing board and now they are allowing 5 mg pills but are " processing this through their system". I spend at least an hour on the day with Anthem and Accredo.
Posted 11/19/2018 8:25 PM (GMT 0)
Your GI's office should be handling all of this. There is really not much you can do about this stuff except call and ask for updates.

My GI's office has a person on staff who only handles the specialty drug approvals and paperwork. My GI gets on the phone with the insurance company about the appeal and discusses it with them.

It's over two months, it should take two weeks, I've had prior authorizations approved in 3 days. I've had offlables approved overnight (in the hospital) and 2-3 weeks for when I first started Stelara.

I'd stick it out with the GI but after this is done then you might want to find a new GI, this is unacceptable.
Posted 11/19/2018 8:28 PM (GMT 0)
Ditto Keith. Your gastero office should have a nurse who helps with this process and does all of the needed paperwork.

You can call your insurance and ask what their policy is for xeljanz. For example, do you have to 1st fail one other anti-tnf medicine (humira/remicade/smponi) BEFORE xeljanz is allowed? That's fairly common with new biologics (xeljanz and entyvio as examples).
Posted 11/20/2018 12:54 AM (GMT 0)
I don't understand how you were approved for 20 mg and then denied because the doc wrote the script in 5 mg pills, 4 x 5 = 20. Makes no sense! And why did they deny it at 10 mg x 2?

I hope you get your meds soon!!
Posted 11/20/2018 1:43 AM (GMT 0)
I hate it for you Talli… I'm awaiting insurance approval for Entyvio now. It's such a shame that patients are being 'punished' due to the insurance companies policies. As others mentioned, your doctor's office should have someone who deals with the insurance and prior-authorizations. On the comical side...I recently was given a prescription for 1 pill, each night for 30 days. Insurance denied it. Doctor wrote new one for 1 pill every 6 hours for 7 days...insurance approved it quickly. It's a shame that insurance companies are now practicing medicine...in MY opinion. Hang in there and try to be patient....it's sure not pleasant in the meantime for many things though. Good luck and hopefully, you'll get approved soon.
Posted 11/20/2018 1:56 AM (GMT 0)
If it is on your insurance formulary and the correct paperwork is filed then it shouldn’t be too difficult to get it approved. There is a process that needs to be followed.

Most likely it is your doctor’s office not filing the paperwork either properly or timely.
Posted 11/20/2018 4:20 AM (GMT 0)
Yup. BCBS, Denied once - had to have a doctor's appointment... Doc wrote a "he's doing great on Xeljanz samples" progress report and sent those notes and we've now been waiting on the appeal. Doc said he'd do a doctor to doctor discussion with insurance if this 1st appeal fails. Having failed Remicade, despite Xeljanz working like a champ, they want me to do Humira or Entyvio and fail one of those before considering... probably b/ those drug companies have biiiig deals with the insurance companies... it's frustrating and.. yes, comical
Posted 11/20/2018 4:51 AM (GMT 0)
Nealzy. May I ask which state you have BCBS in?
Posted 11/20/2018 4:27 PM (GMT 0)

nealzy said...
Yup. BCBS, Denied once - had to have a doctor's appointment... Doc wrote a "he's doing great on Xeljanz samples" progress report and sent those notes and we've now been waiting on the appeal. Doc said he'd do a doctor to doctor discussion with insurance if this 1st appeal fails. Having failed Remicade, despite Xeljanz working like a champ, they want me to do Humira or Entyvio and fail one of those before considering... probably b/ those drug companies have biiiig deals with the insurance companies... it's frustrating and.. yes, comical

If there is a process that was supposed to be followed and your GI didn't do it then who's fault is it? There is more clinical data on Humira and Entyvio.

So I tell my GI that I'd like to try Stelara every 4 weeks (45 mgs) instead of 8 weeks (90 mgs) because I feel like my symptoms are better during 2-6 week mark. He tells me that we probably can't get that covered because there is not enough clinical data on it. He's not even sure that it would work like I think it would because there is no clinical data on it.
Posted 11/20/2018 8:26 PM (GMT 0)
I have already failed ( or they didnt work well enough) 2 other biologics... Humira & Simponi... I have had to be on prednisone since August and stay on it because I can't get Xeljanz. The doctors office has a very nice Medical Assistant but she is obviously inexperienced but trying. Now I realize that Xeljanz may not even work but this whole ordeal has been quite exasperating. Yesterday Accredo told me that my doctors office had to speak with the pharmacist because of a possible drug interaction. I asked them if this was the case why didnt they ask my doctor when he was on the phone with Accredo on Friday.
Posted 11/20/2018 11:46 PM (GMT 0)
noodlesnoodles I'm in Texas. The point isn't more clinical data IMHO. GI had samples, I tried it and noticed improvement after 3 days. Now 5 weeks into it, I'm nearing remission, so... why do I need to take a step backward and try something that may not work when I have something that does work?
Posted 11/21/2018 12:55 AM (GMT 0)

nealzy said...
noodlesnoodles I'm in Texas. The point isn't more clinical data IMHO. GI had samples, I tried it and noticed improvement after 3 days. Now 5 weeks into it, I'm nearing remission, so... why do I need to take a step backward and try something that may not work when I have something that does work?

The placebo effect is an actual well documented effect. Insurance companies go with these policies because of the big picture they are good decisions for the patients and the insurers. I’m not talking about your case, I’m talking about all of the insurance company’s cases. Entyvio has better statistics in treating UC.

Because your GI didn’t follow the procedure setup by your insurance company now your GI is going to have to jump through hoops to get you Xeljanz.
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