Insurance Denied Remicade

[theresad]

Hi guys - drama continues. I just talked our insurance co. and they said that we were denied on the Remicade. Their protocol (Premera BCBS) states that the patient has to try Humira first, and then they will allow Remicade, only if Humira doesn't work.

I explained that the GI wanted us to go straight to Remicade b/c of severity of inflammation @ present and history of fistulas, etc. But they were like yeah, you need to call your doctor and have them submit an appeal with more info.

I'm trying to remain calm but it's getting a little difficult

Anyway, I have a call in to the nurse @ Rush Univ to see what in the world happened with their submission, and why the evidence they submitted was not enough so I will see what they say, and see if we can figure out what got overlooked here to try and fight back on the decision.

In the meanwhile, do you have any suggestions for other things to explore here? We have insurance so it isn't like we can get J&J to pay, and Remistart won't cover the entire thing in the situation where the coverage is entirely denied.

For some reason, I feel like general experience w/ Humira on this board is less positive than Remi, especially in flaring patients. But I'm not sure if that's true, or just something I'm interpreting. The last thing I want to do is step down and only partially resolve the situation, just to get where we ultimately need to be.

Do I just keep fighting the insurance company? HELP!! :ybatty:

 

[Mr chicken]

Ds has been on both
Humira works just as well as remicade for Ds
Only difference is humira shots are more painful
Since your kiddo isn't growing /gaining humira shouldn't be as big of deal
Remicade is billed as a infusion procedure so medical covers that at x%
But humira is billed through the pharmacy plan which tends to be separate from the medical plan and you are stuck with x% copay
In our case humira was significantly more out of pocket

My humira protection plan covers the extra though leaving you with a $5 copay for most folks

 

[Maya142]

My daughter actually did better on Humira than Remicade. The shots are quite painful but are convenient, particularly for busy college students.

We have had insurance deny drugs and then ultimately approve them after we appealed. Don't give up hope if you do want him on Remicade. Sending HUGS!

 

[crohnsinct]

They are both anti tnf's and extremely similar. I think most on here go to remi are simply because they are younger and growing and remicade offers more flexible dosing. I would have no trouble going to humira first. As a matter of fact I think our Insurance has changed their policy and will require humira before remicade for my younger daughter

 

[Mr chicken]

Same here
Our insurance now also requires
We try all classes of drug
Fail each and then humira prior to remicade
It didn't require that a few years ago

 

[Tesscorm]

Dusty's son is in a very similar situation as yours. He was on imuran for years but is now adding a biologic. He was given the choice of remicade or humira and chose humira (he'd also had problems with fistulas earlier on).

I've posted a link to Dusty's thread, it's quite long but if you start at the back, you'll come to her discussion re her son's move to a biologic and the reasons they chose humira.

http://www.crohnsforum.com/showthread.php?t=14388

I think remicade is a bit more commonly used, perhaps because it was the earlier developed treatment?? but, my understanding is that they are comparable in success rates.

Having a son in university, who is on remicade, I can say the infusion schedule can be a problem at times. Certainly not the worst problem to have but, nonetheless, can become a bit of a challenge when trying to schedule infusions, dr apptmts, routine testing, etc. while working with class schedules, exams, vacations, etc. In this sense, humira would definitely make things easier.

If you also look in the Books, research section, David had posted some articles comparing different biologics - you may find the info there to be of interest.

:ghug:

 

[theresad]

Thanks guys! I have to admit that this one threw me for a loop. But GOOD NEWS:

I had a long chat with the nurse last night - I feel like I was really pushy and I felt a little bad afterwards. But this AM, she called me back and said we got the green light for Remicade.

Our GI is with Rush University Med Center in Chicago, and apparently, she had their director of digestive disease personally do a peer to peer call with the doc at Premera BCBS, and that was enough to convince them to change their minds and approve the treatment straight away. I have my issues with big teaching hospitals, but I have to say that they always bring the big guns when it's needed.

So crisis averted and his first infusion is first thing Monday AM. I'm not so sure I should be rejoicing this as a victory yet, but I'm crossing my fingers that this will help him feel better and start to heal

I do actually feel alot better that if Remicade is not successful, we have Humira to explore as an alternative.

And as always, thank you all for your support and guidance. You're amazing

 

[Mehita]

Good luck Monday!!

 

[Tesscorm]

This was actually the thread I was thinking of discussing moving from imuran to humira / remicade discussion...

http://www.crohnsforum.com/showthread.php?t=72130

Realize you're going with remicade but lots of info/links in the thread.

Good luck!

 

[Pilgrim]

I'm glad it all went through. I hope it works quickly!