Pre-Authorization for Remi?

[Mehita]

Just got a letter from our insurance company today stating that they did a review of my son's files and we now need to have his GI do a pre-authorization for Remicade starting January 1, 2017. I'm really worried that insurance will deny it and we'll have to work through the appeals process, maybe even postpone his January infusion.

He's been on Remicade for three years now with no prior approvals needed. He's at a higher dose than the FDA standard (7.5mg/kg & 6 weeks). He's doing great.

What have others experienced with insurance pre-authorizations? Appeals processes? I guess I'm hoping for the best, but planning for the worst.

 

[northwesterner]

Just got a letter from our insurance company today stating that they did a review of my son's files and we now need to have his GI do a pre-authorization for Remicade starting January 1, 2017. I'm really worried that insurance will deny it and we'll have to work through the appeals process, maybe even postpone his January infusion.

He's been on Remicade for three years now with no prior approvals needed. He's at a higher dose than the FDA standard (7.5mg/kg & 6 weeks). He's doing great.

What have others experienced with insurance pre-authorizations? Appeals processes? I guess I'm hoping for the best, but planning for the worst.

Step 1: Google the name of the insurance company, and "remicade." For the most part, the big insurers have a copy of their authorization policy and the necessary criteria to be met posted online. Once you read what they're looking for to give the "ok" you'll know whether this is just a paperwork issue or if you're heading into a battle.

 

[Mehita]

Thanks, Northwesterner. Blue Cross actually included that info in the letter they sent. Part of the reason I'm a little concerned is because my son is at a higher dose and frequency than the FDA recommendation and they mention that as a criteria in the letter.

Of course, I'm assuming the FDA recommendation is 5mg/kg and 8 weeks. We did Prometheus testing prior to his dose increase and at 8 weeks he has 0 Remi in him. I'm just hoping this is all enough "proof" that he's where he needs to be.

I hate insurance hassles.

 

[northwesterner]

Got it. Just wanted to make sure you took a look. In the decade+ I've been dealing with insurance and biologics, we've gone from totally opaque approval policies and criteria to the current setup where the basic approval policies are posted online, which makes it a lot easier to figure out.

 

[Maya142]

You should be ok Mehita. As long as the doctor can make a case for it, which he can.

We were able to get 10 mg/kg every 4 weeks approved for Crohn's. And later, for M's arthritis, "high dose Remicade" - 20 mg/kg every 4 weeks.

We have to do prior authorization every time we switch biologics (which unfortunately, has happened many times for M) and sometimes it happens very quickly (within 5-6 days) and other times it takes a while (weeks).

I think since he's been on Remicade for a while, and you have evidence that he needs a higher dose, it should be pretty straightforward and will hopefully come through quickly. Good luck!

 

[Lisa]

I went from an annual pre-authorization to every 6 months a couple years ago. My infusion clinic/GI does all the paperwork, make sure you are on good terms with the office staff lol.....the receptionist/secretary at the clinic automatically submits for pre-authorization, only once has there been an issue where the paperwork was 'lost' - and she was right on top of it and got things straightened out so I could get my infusion on time.

 

[my little penguin]

Same here the orignal approval
For the med is only good for so many years
Three years is typical
Then you need re approved
We have gone through this for ds humira
Good luck

 

[DougUte]

I am going through this with Humira right now. The FDA guideline is one injection every two weeks. My G.I. changed me to weekly injections. The Prometheus test showed my Humira level was 2.1. At a minimum it should be 5.0. So we had evidence showing I needed the increase. Weekly injections is above the FDA recommended dosage for Humira. My insurance company has denied the weekly Humira, even though we had the evidence of needing the dosage increased.