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Insurance rejecting mesalamine enema prescription

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Posted 2/26/2019 4:08 PM (GMT 0)
Has anyone had issues getting insurance to pay for mesalamine enemas? I have BCBS of IL and have never been rejected a prescription until now. Do they not consider it a medication? I know they get a bit weird with probiotics but I guess maybe I'm missing something

Thanks for any input!


Currently flaring since 12/2018
75mg/day mercaptopurine
40mg/day prednisone
Posted 2/26/2019 4:35 PM (GMT 0)
Haven't had any troubles, myself. If your insurance initially rejects a request, then file an appeal with the assistance of your gasteroenteroligist's office. Often insurance just needs additional information from your gastero's office, something you can't easily do solo. You can win on appeal, if it was a simple mistake.

Did your insurance give a reason for this decline?
Posted 2/26/2019 4:44 PM (GMT 0)
Pharmacy just told me they wouldn't pay for daily doses & it would cost me $2k to fill without insurance. My GI says he's never heard of it being rejected before either but they are telling him they only cover 10 in a 30 day period? That just leaves me paying only $1400 lol.


Currently flaring since 12/2018
75mg/day mercaptopurine
40mg/day prednisone
Posted 2/26/2019 5:27 PM (GMT 0)
They rejected the brand name enema Rowasa or the generic? My insurance refused to cover the Rowasa, but covers the generic
If they rejected the generic enema try to buy it using the discount cards.
Posted 2/26/2019 5:43 PM (GMT 0)
I am no longer on a group insurance plan - Asacol is no longer on my insurance formulary unless I fail on other 5-ASA’s first. I refuse to be a guinea pig - knowing full well Asacol has been 100% effective for me for 30 years with no adverse side effects - I pay 100% of the cost.
I suggest getting your doctor to write an appeal ...
“because doctors should be spending their time doing administrative work” ... sarcasm!
Rx companies’ and the layers’ (to get the medicine to the patient) continual cost increases are unsustainable ... we are at the mercy of big business but their interests lie elsewhere
Posted 2/26/2019 5:55 PM (GMT 0)
Same here, Dipentum is the only drug put me in remission, I moved from a state to another, my new insurance refused to cover Dipentum, my Dr did contacted them to appeal , but they kept sending me rejection letters, I buy Dipentum from overseas because it’s cheaper, I will not sacrifice my remission.
Posted 2/26/2019 6:14 PM (GMT 0)
That sounds odd. I have BCBS in New York and they pay for sulfite free rowasa which is almost $2k a month. The generic rowasa is only $400. Double check what the pharmacy is trying to order. Something doesn’t make sense there.
Posted 2/26/2019 6:29 PM (GMT 0)

momto2boys said...
That sounds odd. I have BCBS in New York and they pay for sulfite free rowasa which is almost $2k a month. The generic rowasa is only $400. Double check what the pharmacy is trying to order. Something doesn’t make sense there.

I very much agree with this. Did your doctor order a 30-day supply, and instruct use 1 per day?
Posted 2/26/2019 6:41 PM (GMT 0)
It could also be that it is only covered with pre-authorization. In such case, the Gi office filing a pre-authorization with BCBS of IL might resolve issue.
Posted 2/26/2019 7:44 PM (GMT 0)
The_Swan
I too purchase from outside the country. The cost difference is crazy and with a high deductible insurance plan it makes no sense to purchase in the US even if the medication was part of the insurance company’s formulary.
Posted 2/27/2019 4:39 AM (GMT 0)
Acmech: this is ridiculous on the part of your insurance company and should be a quick and easy fix. If your doctor's office can't help, don't give up. I had to deal with Express scripts myself once. It took some time but I put it all in writing, including the fact that the next step would be something even more expensive.

Insurance companies and pharmacies really don't understand rectal meds. It must just be an alien concept for them. After years at the same CVS I went to pick up mesalamine enemas two days ago which is prescribed for one a day and they gave me one box (of 7). I just got blank looks trying to communicate the math. I have also had them confuse amount of medication with amount of liquid. For example 60 ml versus 4 grams is a real head-scratcher.
Posted 2/27/2019 7:14 AM (GMT 0)
FWIW, Blue Shield of California paid for mesalamine enemas without a question a few years ago.
Posted 2/27/2019 8:36 AM (GMT 0)
BCBS also denied mine. Doctor contacted them and got a pre-authorization finally, and they approved it. They have been very reluctant to approve any biologics. BCBS pretty much told my doctor what to try and if that didn't work, submit a new request. I do understand...the drugs are SO expensive; but they are what we need to have a life! Best of luck, don't give up to this crappy illness!!
Posted 2/27/2019 5:13 PM (GMT 0)
My mesalamine enemas were also just denied by Anthem. I called Anthem and they said they just needed more info. from my GI and would call him. This was yesterday. I visit my GI today for a shingles vaccine and will be following up to see if Anthem called to get the additional information they needed. I just feel fortunate I feel well enough to call the GI, pharmacy, and Anthem several times to make headway. In the past, I didn't even have the energy to be my own advocate.
Posted 2/28/2019 6:29 AM (GMT 0)
After 3 days and many phone calls I have lost all hope for our planet. Turns out what could have been taken care of in a simple follow through by the pharmacist was the only reason for the issues. My GI prescribed a 30 day supply 1/day which is apparently not what the manufacturer recommends so they just needed the GI to confirm the dosage before accepting the rx. Express scripts was blown away the pharmacist called to tell me it was denied and I would have to pay full price. I believe I'll be finding a new pharmacy....
Posted 2/28/2019 1:42 PM (GMT 0)
Yikes. Often it is just that, a simple mistake and no follow-through. You/I should not have to be the middleman but often we MUST to make sure things work out, for reasons like the aforementioned.

Hopefully identifying the problem now makes a resolution a lot closer, an approval and you getting your medication for a reasonable price.
Posted 2/28/2019 5:05 PM (GMT 0)
Glad it worked out and sorry you had to go through this. I have learned that we have to advocate for ourselves and always ask questions!
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