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My Insurance Just Rejected My Remicade #279867
01/29/18 05:34 PM
01/29/18 05:34 PM
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ThreeG Offline OP
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ThreeG  Offline OP
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I am really freaking out. You may remember that my last infusion was cancelled due to a request for pre-authorization (my last one was less than a year ago). I am now 2 weeks overdue and feeling it. I am very stiff, and symptoms I had forgotten about have returned. I just got a huge thick packet telling me the insurance won't approve it because it isn't medically necessary. It seems to relate to the dosage. My doctor was trying to get it up to 8mg/kg. I had been taking 7mg/kg, but the benefits from the infusion always seem to run out about 2 weeks before the next one. She thought raising the dosage would be easier to get through insurance than getting them to agree to infusions every 6 weeks. They are now saying that 5 mg/kg is all that is approved for AS. At the moment, this means I get no Remicade at all.

I feel like the rug has been pulled out from under me.The good news is that I have an appointment with my doctor tomorrow.

Has anyone had to fight for something like this?

Re: My Insurance Just Rejected My Remicade [Re: ThreeG] #279868
01/29/18 05:46 PM
01/29/18 05:46 PM
Joined: Mar 2013
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SouthernMoss Offline
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My husband has several medical issues, and he has run into this problem multiple times, most recently because insurance didn't want to cover an inhaler he needed for his lung condition. Your doctor just has to keep hammering at the insurance company. It's very frustrating.


Ginny - 57 year old female
Dx with USpA in March 2013; changed to AS in July 2015
Iritis and Scleritis
unicompartmental knee replacement June 2014
MTX, Humira, Cyclobenzaprine, plus Celebrex as needed
Supplements: Folic Acid, Vitamin A, Vitamin D, Calcium, Fish Oil, Melatonin, Culturelle probiotic
Re: My Insurance Just Rejected My Remicade [Re: ThreeG] #279869
01/29/18 06:39 PM
01/29/18 06:39 PM
Joined: Jun 2016
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Winston Offline
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Appeal the insurance company's decision. It's, unfortunately, not uncommon. In the meantime, see if the drug company can help you. The mfr of Enbrel will, for example, give you one or two doses of Enbrel per year free if you are experiencing problems with your pharmacy, get a faulty injector, etc. It wouldn't hurt to call them to see if Remicade has a similar program.

Re: My Insurance Just Rejected My Remicade [Re: ThreeG] #279871
01/29/18 08:17 PM
01/29/18 08:17 PM
Joined: Aug 2013
Posts: 154
Madison, Wisconsin, USA
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Cake Offline
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Madison, Wisconsin, USA
I feel for you. It is so stressful dealing with insurance when we are dependent on expensive medications and they have so many hoops we have to jump through. I am starting Medicare next month and have probably spent over 100 hours in the past two months trying to figure out which plan will cover all my drugs, doctors, etc. Right now I am working on the form for them to approve Enbrel.

Maybe you can contact Remicade to see if they can provide any assistance: https://www.remicade.com/rheumatoid-arthritis/remicade-support/medication-cost-support

best wishes!!

Re: My Insurance Just Rejected My Remicade [Re: ThreeG] #279878
01/30/18 12:59 AM
01/30/18 12:59 AM
Joined: Jun 2012
Posts: 506
Los Angeles, CA
RAHMBA Offline
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ugh, I wish medication decisions were left up to the person taking the medication and their doc. The SAA site has a slightly different link for the Remicade assistance program. I've heard good things about the support programs. http://www.spondylitis.org/Patient-Assistance-Programs#REMICADE


AS, U C, Iritis, migraines. HLA-B27neg. Yoga (instructor) & spin. No meds at this time. Dx 1989. SAA member/donor since 1993. All my posts are personal opinion/feelings and do not represent the SAA. Help find a cure & support others by donating to the SAA.
Re: My Insurance Just Rejected My Remicade [Re: ThreeG] #279882
01/30/18 01:40 PM
01/30/18 01:40 PM
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Posts: 1,392
Whidbey Island WA
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WhiteCell Offline
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Your doctor's office can get this changed by submitting (and quickly) reasons you need the higher dose. Your doctor must prove what symptoms get worse without the increased dose. eye involvement? They should be firm and rapid. Why have they not done this two weeks?????


Starting at 18 yrs old > Reiter's Syndrome. Diagnosed 2001 Ank Spon.
Started Remicade 2002 - 5mg/kg every 7 weeks.

Right Eye Glaucoma- Trabeculectomy/lens replacement 2006.
Right eye DSEK Cornea Transplant 2009.
Right eye Ahmed Shunt 2016.
Right eye DSEK Cornea Transplant 2016.
Supra Ventricular Tachycardia. 2004. Cured by RF ablation 2008.

ICU RN - Seattle, WA

~Grasp The Challenge and Succeed~
Re: My Insurance Just Rejected My Remicade [Re: ThreeG] #279884
01/30/18 02:37 PM
01/30/18 02:37 PM
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ThreeG Offline OP
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Thank you all for the ideas and support. I just saw my doctor, and they were trying to set up the peer-to-peer call to get approval when I left. She did say she has never seen a case like this where they rejected a request for a patient already receiving treatment. I did some reading yesterday and that seemed to suggest that if the insurance company is going "by the book," maybe we'll have better change getting infusions every 6 weeks at a lower dose than getting the higher dose. The Remicade site does say for AS 5 mg/kg every 6-8 weeks. I have been very impressed by Jansen's financial program, so if their patient support in other areas is equally great, you guys may be right that that's the next avenue. Hopefully I'll hear something today about progress on the peer-to-peer call.

This is so very frustrating, and yet I know that I am actually one of the lucky ones.

Re: My Insurance Just Rejected My Remicade [Re: ThreeG] #279893
01/31/18 08:22 AM
01/31/18 08:22 AM
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Jeffn Offline
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Hope it works out. Remicade is specified at 5 mg/kg every 6 weeks from what I saw.


Dx w/ AS in 1985. HLA-B27+. Left total hip replacement in 1998, lost 2" of height due to osteoporosis. Relevant meds include Remicade, Oxycontin, Percocet, Lyrica, Soma. 7 hour spine fusion surgery in April 2014 for cervical spondylotic myelopathy and radiculopathy. Tried for a year to return to work and couldn't make it past a 5 hour day, so was forced to go on disability in 2015 and haven't been able to attempt another day of work since then. Living to help others now.
Re: My Insurance Just Rejected My Remicade [Re: ThreeG] #279908
02/02/18 02:12 PM
02/02/18 02:12 PM
Joined: Jul 2006
Posts: 6,552
New York
Banana Offline
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Banana  Offline
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New York
Are you also taking MTX? Because the insurance companies are much happier if you are taking that too. It boosts the effects of the biological and is highly recommended for Remicade. I would go for the same dosage with MTX added and see if they are happier. Than you can apply in a couple months for every 6 weeks or whatever. BTW, I had a nerve reaction at that high dose of Remicade. which left when I stopped it.


Anna


Actema IV once a month (with pre loading for allergic reaction), Cymbalta x1 daily, Arava 20mg daily. Diagnosed with AS in 2004, suffered undiagnosed since 1982.
Re: My Insurance Just Rejected My Remicade [Re: ThreeG] #279909
02/02/18 02:56 PM
02/02/18 02:56 PM
Joined: Nov 2016
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ThreeG Offline OP
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ThreeG  Offline OP
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Thanks, Anna. I do take methotrexate (thank goodness because it really keeps my small joint pain under control). Strangely, they don't even seem to care about that. They initially approved the Remicade when I hadn't been on the methotrexate very long. They seem to be quibbling entirely with the dosage.Maybe they are right to, but it just would be nice if they drew their line in the sand before I was overdue for an infusion!


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