Remicade BCBS pre authorization required with Medicare

I don't have any factual information to give you, however, this doesn't surprise me. Keep in mind private insurance requires pre-authorization. The one thing to keep in mind is Remicade is now available as an injection after the first infusion is done. A person would have to look at part D.

So far I’ve never been asked or required preauthorization for Medicare. I have blue shield as my secondary but my understanding is Medicare does not require preauthorization and your secondary has to pay on any claims that Medicare pays.

And yes you are correct that Medicare covers infusions under part A.

I’m pretty sure entyvio is now available in U.S. as an injection and an dreading if Medicare requires me to switch which would mean a switch from part A to D and THAT would be a major money issue for me. 🤞🤞

That's crazy, Clo! Haven't they considered that you are "stable" because you have regular infusions? What did they do with your first infusion of the year? Are you on an Advantage plan?

Hey...
I was gifted with a nasty surprise. My husband's insurance won't pay what they normally pay unless I sign up for Medicare.....so I signed up. 😡😡😡

Everything changes when you retire. They should forewarn you.

I now have regular Medicare with my husband's retirement insurance as secondary. Everything I read indicated if Medicare pays they pay.... But there's one line in the booklet under Remicade infusion which says that all speciality drugs must be pre authorized. And they mean all. But the infusion place said not so if it's paid for under Medicare part A.

BCBS said as of 01.01.24 all specialty drugs even those administered by vein and paid for thru Medicare part A (including chemo drugs) must be pre authorized. I have received 2 infusions this year that were not pre-authorized. My charge was about 1k per infusion. Infusion place is apologizing... But that's not going to pay my bill. So if they don't approve by 04.04 I won't get my next infusion until I pay my bill.... 2k. The Remicade is not covered under an assistance plan because it's paid for under Medicare. I did not get Medicare part D because the BCBS prescription program covered more drugs and I would be eligible for the payment assistance with manufacturers if I had to switch. Can you say irony????

So now I'm on the phone all day trying to to rectify this and a couple of other insurance glitches. I am so frustrated.

Clo

Clo... I do really hate it for you. I went through the insurance nightmares with Remicade, then Entivyo, then Humira, and then again with Rinvoq. Insurance doesn't care how the patient feels. They don't feel your increased stress, anxiety, and worry. They don't care! I will say that BCBS and Medicare have been good to me...even after all of the hoop jumping. My copay is over a thousand bucks every 90 days for Rinvoq. I can understand the insurance companies' complaints though. Drug prices in the US are just ridiculous; but they know that we will pay what we can to continue to function. I just wish the doctors could practice medicine and prescribe what they know will work for their patients without insurance interferance. But...just don't give up. BCBS is as good as it gets, I think, when it comes to insurnace. I will be forced to switch to Etna next year. God only knows what surprises that will bring. Best of luck to you and just keep up the fight.

Not sure how it works with using a spouse's employer insurance along with Medicare, but for my own insurance even if I had signed up for medicare (I haven't), my employer insurance would be primary and everything needs to be approved by them. Since that was the case for me I see no reason to sign up for medicare until I stop working as I would lose that co-pay assistance.

I agree with Straydog -- maybe it's time to get your own supplement policy

Speaking of co-pay assitance.... Accredo is the specialty pharmacy I use. I had zero problems with them last year. This year they drag their feet in submitting claims and I had to pay for my first couple infusions from the infusion center because I didn't max out my out of pocket that would have been covered by the med from Accredo if they had sent in the first shipment in January. I hounded them until they finally submitted that claim and now I am maxed out. I checked this morning and they still haven't submitted Feb or March yet (my infusion was in early March). My guess is that if I hadn't hounded them they might not have submitted Jan yet either. Now I don't care because I am maxed out. You would think that a business that depends on payments from a 3rd party would hurry and submit those claims so they could get paid. It's such a difference from last year. When I have to get a new pre authorization in June I am going to try switching the Optum. Hopefully they will be better.

It's time to move to a Medicare supplemental plan, we have UnitedHealthcare & not one claim has ever been denied. Look at their plan D for medications.

We went from Aetna to BCBS of Texas, both company's had a patient online portal, I could online to see what was paid. BCBS writes various plans in Texas, it all depends on the employer. They preferred this instead of mailing out EOB's. You really need to establish an account.

Your husbands plan will not pay the full 20% ever, even if they approve Remicade. Your will have a yearly deductible, co-insurance charges plus a co-pay.

Like I said before I kept it 2 years for the prescription card & when they jacked up my premiums I switched my coverage.

Well, I have been spending hours on the phone almost daily.

We have cancelled my 04.04 infusion. BCBS denied our request for Remicade. They said it wasn't medically necessary, they don't approve it for every 6 weeks... It has to be every 8 weeks. They don't approve it at 10.. I explained I have been getting 10 at every 6 weeks since 2017 and they have paid for it.... Did not matter. My GI has appealed. BCBS is doing a peer to peer on April 11th. But the only doctor they have available is a Brain doctor. Does this concern anyone else?

I've filed a complaint with the agency that takes care of my spouses retirement insurance. I've called my senator and congressmen. (I have to try them again tomorrow) Tomorrow I am also calling the state insurance commissioner to file ar complaint. The infusion clinic hasn't had 1 other issue with BCBS customers where BCBS is secondary. It's ridiculous. If Medicare pays they should just pay.

This stress has about killed me.
My fistula is going wild, my arthritis hurts so bad I'm using a walker/chair to get around my house, my thumbs aren't working because of the arthritis, my Psoriasis patch has started to break back out, I woke up and had to change my bedding because of the night sweats, my right eye is turning red where I always get that stupid uveitis, the heat intolerance had my gagging and dry heaving in a cool shower today..the nausea and twisting intestines is occurring periodically
...and now I'm constipated or I'm partially obstructed. This happens occasionally during week 6... Not usually all at once...but sometimes it's close to this....But I know the Remicade knocks it all back down.. but this time I don't know when I'm going to get my Remicade. I'm so frustrated. Plus I made a young girl cry in the phone today. I wasn't screaming, and I wasn't really mean... I just told her she works for a company that was doing something that would impact my health and QOL.... Then I gave her examples....while I was crying.

I can't change my insurance until next November--if BCBS hasn't killed me off by then.... But I will be looking carefully at other things. I do know that BCBS came out with a Medicare drug program that you had to opt out of to keep their pharmacy benefits. I opted out because the assistant programs won't help you if you have Medicare. Now I'm wondering if this isn't BCBS wreaking havoc trying to force you into the Medicare drug program.

I loathe UC and Crohn's.

Anyone got any ideas on who else to complain to?

Clo

Sorry that you are having to deal with this mess! I hope you can get it straightened out until November.

@Flowers, Medicare is paying, it's her husband's private insurance that is giving her problems.

Oh, Clo! This is so awful! Hang in there and know that you can come here and vent as much as you need to. Insurance is so frustrating. Hope your docs can help you get this straightened out soon. Does BCBS want you to go on a biosimilar or how the hell do they think your should be treated? Your doc should be able to win the appeal ... he will need to show your history and the need for the dose/frequency you are on. If they insist on a biosimilar I can recommend Inflectra. I was so worried when I was forced to switch, but all is well with no side effects.

I may just work until I die because my employer insurance is pretty good. They have some annoying things, but mostly they are good. Navigating Medicare sounds like such a nightmare.

@Flowers, you are absolutely right, with regular Medicare & a supplemental plan there are no surprises.

Plan D for medication coverage varies a lot, different tiers involved & what they will cover. You can't assume the coverage on Plan D being the same every year, just like employer insurance it changes every year. Even choosing one is fairly simple, make a list of what you take & compare the cost. GoodRX is cheaper for me than what my plan pays, go figure.

Clo -- I have complete faith that your docs will get this straightened out. I just hope it happens sooner rather than later. Do whatever you have to do to try to keep stress at a minimum. I know much easier to say than do. My niece gave me some "special" gummies -- I can recommend them if they are legal where you are ;)

Flowers -- as long as I am still working and not signed up for SS I am going to skip medicare completely and just keep my work insurance. I won't get penalized later because my employer insurance qualifies. Once my 1st infusion of the year is billed, it maxes out my out of pocket for the year ($3000) and co pay assist covers that. This way all I have to pay is pretty much just my share of the premiums (approx $200/month). All my meds, tests, dr visits etc are all completely covered. Pretty sure that even the best plans with Medicare with all the premiums, co-pays, drug costs would be more than $2000/year total. I do have to pay extra for vision and dental insurance -- about $30/ month and that completely covers regular dental care, and a big chunk of getting new glasses every 2 years. I am very grateful for my work insurance and I know how lucky I am to have it. My previous employer had good insurance but the premiums and deductibles were a LOT higher. That's difference between a small employer and a large one -- better insurance lol