Problems with insurance covering Remicade?

[texasagg02]

Hello!!!

Looks like I will be starting Remicade, (Pentasa and 6-MP not working for me). I just looked up remicade and it is an exclusion on my policy (so was pentasa). Anyone have issues getting it covered??? Starting to think my issuance is crap, already had to stop taking pentasa because of my insurance. We pay a lot each month for this coverage, (united healthcare)… hoping my dr can get it covered but we could not get them to cover pentasa a couple months ago. I am at a loss because I need the remicade and feel like they are bullying me into taking what they want me to take and not what is best for my case of Crohn's...

 

[Clash]

Is it an outright exclusion or do they require you try other meds first? Is it just remicade or all biologics such as humira or Cimzia?

You can Google Remistart and see if they can help you.

 

[texasagg02]

It says exclusion, humira looks like it would be covered as a "step" therapy. My dr said it would be better for me to do remicade first… I did read something that said something about it being billed differently and might not be considered a RX?… guess we will see what the Dr says.

I did look up Remistart, the 3 steps to start it is that you have a commercial insurance which covers remicade...

 

[Clash]

It may be that remicade has to be oredered through a specialty pharmacy. My son went straight to remicade after dx and I do remember it could be covered under prescription coverage or our BCBS but it was more expensive under the prescription. Honestly, I don't remember the details as it has been over two years.

I do know there are other members who used humira first either due to their choice, GI decision or insurance requirements and they have had good results.

I'm going to tag theOcean for you as he has experience with both.

Hope your doc can work things out.

 

[theOcean]

Clash: She, but thank you.

I have had experience with both Humira and Remicade, yes, but I live in Canada so it's a bit different here. I definitely was a case where I desperately needed it, because I was so incredibly sick and had failed Pentasa (and then eventually Remicade due to antibodies). Humira has been a life-saver for me. If you have any questions about either biologic I'm happy to answer, but unfortunately for coverage issues I won't be too much help.

 

[Clash]

Ughhh theOcean, I mean she each time I tag you, but for some reason usernames are always a he to me. I also grew up believing all dogs were boys and cats were girls...odd I know!

I knew you couldn't answer to coverage but thought you could possibly give the OP an overview of how each of the biologics have worked for you.

texasagg02, Johnson and Johnson also has a program for remicade if you don't have ins or it won't cover it. I'm not sure if it is based on income, I know Remistart isn't but not sure about the other.

 

[theOcean]

Clash: Haha, no worries! I've heard of a bunch of people that do that.

texasagg02: Remicade unfortunately wasn't too effective for me, but it's been a wonderful biologic to many people I know! I had high antibodies to it almost immediately, possibly since it's made from mouse protein so people can react to it adversely easier than other biologics. That said: it's one of the best and most powerful out there, and I have a friend who has been on it for nine years and it's been a miracle for him.

Humira is humanized and less likely for people to have adverse reactions or side-effects to as a result. I went on Humira after finding out I was allergic to Remicade, and needed to treat a fistula I just had a fistulotomy for. It's been a miracle medication for me and has saved my life -- it's even healed my fistula, which is so difficult and so rare.

 

[texasagg02]

TheOcean: I thought all along we would do Humira first, I am not in any pain or really having any symptoms at the current time. I am on a steroid that they want me off of but we can not wean me off that until I get a maintenance med that works for me. =) When I went to the dr on Wednesday he said that he has read some stuff lately that suggests its better to do the Remicade first and if that does not work then do humira. I am looking forward to starting one of them! I have talked to so many people that said they are a life changer!!!!!

Clash: I will look into the program through Remicade in case my dr can not get it approved =)

 

[WebJunk]

I am also have North Carolina insurance although its BCBS of NC. Remicade is not on any of their prescription lists (not Category 4 or 5) but my Doctor at the Mayo said it just takes a bit more paperwork to get approved. That is for the prescription. Then have to see what insurance covers for the infusion as Remicade is not self-injected.

Was on Humira over a five month period but the side-effects were worse than my Crohn's although my inflammation is greatly reduced. He wanted me to start Cimzia but I don't think I could do the syringe. (I'm a wuss when it comes to needles) So the only medicine left for me to try is Remicade. Side-effects have been a huge problem for me with all meds so after that he will try holistic treatments.

 

[texasagg02]

WebJunk, what have your side effects been? I had headaches on Pentasa, then 6-mp made me so sick! I was on phenergen with it and that helped but my liver enzymes starting going up. On to Remicade, still waiting to see if the Dr can get it approved. I looked up BCBS of NC incase United rejects it. It was not on their list so it makes me feel better that your dr got yours approved. =)

 

[WebJunk]

If you mean the Humira, had several. First was the feeling like the flu. It started like most people for a couple of days after injection but the last couple of months it would last until the day before I next injected.
Others include:
weird rash on upper arms, chest & neck. headaches, very stiff neck, short of breath, eye pain, hair loss. The last one for personal reasons I consider the worse
Also not sure if it was the Humira but for several months I have had bad joint pain and muscle pain to the point I went from exercising six days a week for the last forty years to having to stop completely. The joint pain is much better lately since stopping Humira but the muscle pain is still there. I also have had extreme fatigue the past 3-4 months which has not improved.
I was diagnosed with Fibromyalgia over twenty years ago but my GI doctor said last week that he thinks for "some reason" it has went to the extreme side. Am functional only about 2-3 hours/day.
Also have had what seems like pleurisy off & on for several months. When last week I was traveling to the Mayo Clinic, had twice where people asked me if I needed a doctor or ambulance as I must have been holding my chest because of the pain.

Some symptoms have improved in the month+ since I stopped the Humira.
While some of these can be contributed to Crohn's disease, my blood work came back basically normal & my inflammation is greatly reduced so related symptoms should improve as well.

 

[Lisa]

It is interesting that having the same insurance company but in different states various the coverage.....I have united health care here in NY and remicade is covered 100 %!

It is billed as chemotherapy, with no co-last. I do have to get pre authorization every six months though....so far no problems with that.....

 

[WebJunk]

Different states have different coverage. I just switched a few months ago from Blue Cross of Florida to Blue Cross of North Carolina. Fortunately I have houses in both states to allow the switch. The medication & other coverage in Florida is horrible compared to NC, both with Blue Cross.
Also ordering specialty meds like Humira, Cimzia, Remicade, etc. In Florida they give me three specialty pharmacies very strongly pushing their own: Prime Therapeutics who I had problems with. In NC they offered me a list of two dozen and did not seem to care which I chose.

 

[my little penguin]

Things to realize - remicade may not be covered under your prescription plan -
It doesn't have to be .
Remicade is a medical procedure covered by your major medical same percent copay too unfortunately so 10% , 20% ,30% etc of the infusion bill .
DS total bill was $$$$$.
Remistart helps cover the difference.
Just like any other major procedure it would need to be approved.
We made the mistake of calling the prescription plan first -
That was a nightmare .
But eventually got fixed .
Humira actually took longer to approved since it was through the prescription plan.
Both worked for DS but remicade caused allergic reactions in his skin first and later his whole body so he had to switch .
Humira is painful and took longer to work but so far so good .
Good luck

 

[WebJunk]

Seems to Depend on the insurance plan, treatment & how its billed. It appears for mine and would have been the same in Florida, the medication is covered similar to Humira after approval. The infusion is a separate item billed as a procedure.