No go on Remicade

[Starla86]

I had my first infusion scheduled for this Friday and already got approved for Remistart and of course my insurance has to deny me for Remicade I am so dissapointed and just plain scared, my dr said that this was kinda my last resort before surgery. I am not compatable with 6mp and am allergic to the other antibiotics that she wanted me on. I am currently on Entocort but it has not cleared up all of my symptoms and I am still in so much pain. My dr personally called me to say that she was going to write to them for an appeal and that hopefully that will work, but in the mean time I am still hurting. ARRRRGGGGG!!!! Sorry but I was really hoping that this would work since I have read about how this has helped so many people. I am only 24 and I have a young son and surgery is just not a realistic option for me right now. Sorry to vent but this really messed up my Crohns plan. Thanks for reading.:angry-banghead:

 

[Lisa]

did they say why they denied the Remicade? Hopefully the appeal will work!

 

[saidinstouch]

Unfortunately you will have to appeal and if that fails, appeal again and threaten to report them to your state's insurance commissioner. It is an approved standard of care for crohns disease and they pretty much cannot legally deny you that. If they do, then force them to approve humira or cimzia which will be somewhat cheaper for them (and you) and tell them they have no choice in the matter. If you are forced to undergo surgery because of their refusal to approve the treatment, tell them you will SUE them for damages, lost wages, and emotional harm. Make sure when you make that phone call you get the name of the person you are talking to, the call record number, and tell them you want the call recorded. If they say they cannot record the call (A boldfaced lie since all companies record their calls to protect themselves) then tell them you are recording the call and do so. Make sure you tell them you are recording the call to prevent any legal issues with if it is a one party or two party state for recording calls.

From there you just have to call and call and call and call and call. Also, get your doctors office to call and if necessary spend $100 for an hour of a lawyer's time and have them draft a letter and call as well. You will get the medication approved, if you follow a plan like this, it will just take time. Their strategy is deny first, approve only the persistent second. I hope this "guide" helps you some. We have all (mostly) been through this before and persistence is the key to getting approval. Also, ask for supervisors and managers when you call. If the first line call center says they cannot do that, tell them they can and they will if they value their job, then get their name and employee id number. If they refuse, call back and ask the new person for the information on the person you just talked to (it is in their system guaranteed) and write it down then explain you need a supervisor to report an issue with a call center employee. That will get you through usually.

If you have to, take a day and call them nonstop talking to different people every hour, then do it the next day and day after.

 

[Jer's Girl]

I'm so sorry. That is so unfair. I hope that you get what you need soon.

 

[tiloah]

Unfortunately you will have to appeal and if that fails, appeal again and threaten to report them to your state's insurance commissioner.

This is what I went through to get my Humira. Only instead of threatening we actually called the insurance commissioner. Needless to say it was approved pretty quick after that.

All is not lost. You CAN get your insurance company to cover it. They're just going to drag their feet as much as they can about it.

 

[saidinstouch]

This is what I went through to get my Humira. Only instead of threatening we actually called the insurance commissioner. Needless to say it was approved pretty quick after that.

All is not lost. You CAN get your insurance company to cover it. They're just going to drag their feet as much as they can about it.

Yeah, calling your insurance commissioner is a good way to get things done faster. A lot of times just the threat is enough since they don't want a bad report for something like this since these kinds of violations are only the tip of the iceberg usually. However, if it doesn't work, definitely call them and file whatever reports necessary to file a complaint.

 

[Starla86]

Good news....somehow between my dr and the infusion center they got Remicade approved!!!! I am finishing up my infusion now and although Im super tired everything else seems to be ok. Thank you all for your advice!! Hopefully this works!!!

 

[ameslouise]

Congrats! Great news - I hope it brings you relief very soon!

- Amy

 

[saidinstouch]

Good news....somehow between my dr and the infusion center they got Remicade approved!!!! I am finishing up my infusion now and although Im super tired everything else seems to be ok. Thank you all for your advice!! Hopefully this works!!!

Glad to hear it. This is the most common occurrence where an appeal is needed at first and they get it right. However, I was setting you up for the mindset and tools in case it didn't go as easy for you. This drug really helps people, so have faith you will get some relief within a week or two of starting!