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Reimbursement for a teenager in PA.

A friend’s teenage son was denied insurance coverage in PA for Remicade at a “higher” dose. I have suggested she pursue Janssen’s CarePath for assistance. Does anyone else have suggestions for getting treatment when they cannot afford to pay for it out of pocket?
 

Lisa

Adminstrator
Staff member
Location
New York, USA
First the doctors office should appeal the decision - was the mg/kg dosage increased or the interval shortened? Good suggestion on carepath - that is probably the best way to go.
 
First the doctors office should appeal the decision - was the mg/kg dosage increased or the interval shortened? Good suggestion on carepath - that is probably the best way to go.
I think increased. He was doing extremely well on it and now he can’t get and feels bad each day. Thank you Lisa.
 
Lisa, his dosage of Remicade was decreased by half if that makes sense. My friend will pursue CarePaths. Thanks again.
 

my little penguin

Moderator
Staff member
Most insurances are currently pushing back on higher dosing or higher frequency of biologics.
Jansen typically helps cover the copay difference if your insurance approves the drug but not if you have commercial insurance that denied it at a higher dose or frequency

We are currently fighting this one for Stelara
Same issue after years of higher frequency
Insurance refuses to cover higher frequency
But will cover the drug at lower frequency

Docs office has to appeal -typically twice
First appeal is paper records
Second appeal is better if they can do “peer to peer” -phone call with an insurance doc
If those are both denied then you can get an independent review by a third party
This should all be spelled out in the denial letter recieved by the parents
Request a case manager through the insurance to help

Second option is see the social worker through the hospital -they can help expedite application to medical assistance-state insurance
They cover kids with crohns under 18 regardless of parents income -
It acts as a secondary insurance
That would be a long shot for them to cover it at the higher dose given the primary denied it
But worth trying

Once you have commercial insurance deny it
It’s very hard to get other options to help you cover it
Non for profit helps really have restrictions to get help to those who have no insurance
Commercial insurance is not permitted typically
 
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