It has been a long time since I have checked in, but I need to vent. I have taken Remicade since 2013 and have had great results. I’ve also had the same insurance for years. Remicade has always been covered. In October of 2020 I got a letter from my insurance that they were denying Remicade. Never mind that they provided a one-year preapproval and by this time I had had 10 treatments. All of a sudden all of the explanation of benefits started coming to me stating that I needed to pay my doctor for each infusion. Each infusion is $20,000 so if you do the math that means I owe $200,000 to my doctor. My doctor of course was very nice about it he contacted my insurance and they said they did not approve the medication even though my doctor has proof in my file showing that they did approve it. I end up continuing Remicade and I get another denial notice. I sent this to my doctor he once again appeals it, he gets a denial letter, so he ends up calling my insurance. After going back-and-forth my insurance says you can put her on Inflectra. It is the same medication however it’s made by a different manufacturer and costs less. I had two treatments, and just last week I got another denial letter, this time denying Inflectra. I am beside myself and so is my Doctor. I am so angry. I do not understand how insurance companies can do this. I really do not know what other medication options I have. I have been on Enbrel, Humira, and Simponi. I also have continued to take Methotrexate all along this journey. I am just disgusted with how pharmaceutical companies and insurance companies don’t give a crap about patients. If I end up disabled, what will they deny at that point. Vent over.
Oh Suzanne that must be so frustrating. Not being able to get on a med you know works must be really hard.
I do know there are still quite a few more effective meds to try, but sounds like it all depends on what they’ll approve, and I don’t understand why you should have to go through trying them when you have one that works.
Being in Australia I can’t offer any advise, but I’m sure people have talked about places to get information on this in the past and hopefully someone from North America will be along shortly with something more useful for you (@Stoney? @tntlamb?).
Hearing your story makes ME angry, Suzanne! How can insurance deny you something your doctor has said you need? I really don’t understand: how can the insurance bureaucrats trump your doctor’s opinion? Oh boy …
I do think this is a question on which @tntlamb could shed some light. He’s much more adept at dealing with these things than I am.
Just want to say how sorry I am that you have to put up with this as well as with PsA. It’s bad enough without this kind of interference.
Every insurance Company has whats called a formulary. There they list how they cover each medication in terms of copay. its hard imagine you haven’t more than met your deductible and blown the top off your stop loss. I have never heard of a company classifying IV therapy as prescription therapy. Someone doesn’t know their ass from a hole in the ground. and I have a bad feeling that part of the problem s who ever is doing the pre-auths for your Doc. In any event unless you are on medicare, there isn’t much they can say. Remicade is a part B treatment on Medicare so there is no insurance company involved. First thing monday morning call [(217) 782-4515] https://insurance.illinois.gov/ be prepared to photograph the documents and them. (you can do it later as I am certain there is a form. In the event you have some sort of Catastrophic insurance only or a very wierd coop you should be fine, If you do for Gosh sakes get a ACH policy on tues the enrollemnet period ends aug 15 Also call [800-652-6227] and ask for a patient advocate. J & Jtakes no BS from insurance company clerks which is what is happeneing in regards to inflectra call 844-722-6672 Pfizer can be even nastier. Either company will supply the med at no charge if push comes to shove. Hells Bells if nothing else have your doc admit you… Then really stick it to theinsurance company.
Also please look into Patient Assistance Programs.
The same thing happened when I started Humira years ago, they told me go for it and then after a few treatments I got a denial letter. I did some poking around and realized that Abbvie will provide the drug free of cost in this predicament. I think I got the drug this way for about a year.
Turns out a lot of these pharma companies have programs to help uninsured or underinsured folk. The denial letter would constitute underinsured status. They just want you to be on their drug, so that when your insurance changes or kicks in, then they already have you “hooked.” It’s ultimately to their advantage to have as many patients on their drug as possible.
Check this out for Remicade.