Remicade - cost & insurance

[cassimw]

My daughter may be starting Remicade soon. Our insurance company has pre-approved coverage for 6 months. After that, we have to seek approval again. Is this normal? Should I worry that it won't be re-approved?

It is "open season" at work for insurance selection right now. I've been pleased with our insurance over the years, but this Crohn's dx is brand new and this is the first medicine/treatment we will be trying. I'm not sure if I should try to find a different insurance that has more certain coverage? Or just not worry that they will re-approve.

Anyone have a similar experience? Insight?

 

[Clash]

I don't have any experience with re-approval personally. Maybe some of the other parents do.

Also, make sure you sign up for Remistart. Its a patient assistance program that is not based on income. It will pay a majority of the out of pocket expense. I think we paid about 248.00 a year out of pocket between our health insurance and remistart. The GI should give you the sign up info or you can Google it and get the sign up started online.

 

[Jmrogers4]

Ours approved for 6 months at first and now it is approved for a year at a time.
The GI's office has always submitted for approval for us. We have had to have new approvals for changes in intervals or dosage. My son started out at 5mgs/kg every 8 weeks but we did not even make it to 8 weeks on that first one. What generally happens with us is we decide he warrants a change in either time or dosage at the current Remicade treatment and they submit for approval of that change so that by the time the next appointment for infusion comes around we are good to go. It happened a lot within the first year for us. We shortened the time from 8 to 6 weeks then upped the dosage from 5 to 7.5 and then to 10ml/kg and then back out to 8 weeks at 10ml/kg which is his current dosage and we've been on that for about a year.
So right now he gets 560 ml every 8 weeks based on his weight of 122 pounds so they actually end up throwing away 40ml because of the way it comes it adds up to 600ml but because our insurance has only approved the 10ml/kg they can't go above that amount even though his GI would really like to just give it to him and thinks he would most likely benefit from the small extra which would take in any growth over the next 8 weeks.
He is weighed at the beginning of each infusion appointment and the appropriate dosage is called down to the pharmacy at the hospital so that way if he has gained a lot of weight over the previous 8 weeks his dosage can easily be adjusted. I don't think every hospital/infusion center does it this way though I know some have it that the medicine is already pre-ordered so they would order based on their weight at last infusion.
We have not had any problems with approvals and now just get a letter once a year from the insurance company saying he has been approved for another year.
I highly recommend Remistart as well. We did not use it as we had already hit our deductible and the medicine was covered by our insurance. It is not billed through our insurance as a prescription med so not subject to the 50% we would normally pay for name brand Rx

 

[Lisa]

I get approval every six months, my GI doctor's office does all the paperwork.....

As for cost, I have no out of pocket, it is billed through the hospital where I get my infusions. I have United Healthcare through my job.....

 

[my little penguin]

Be aware
I just read on another forum
Bcbs of mass is changing from covering it under medical to requiring patients get it from specialty pharmacy and then sent to the facility to give it which some infusions centers allow and some don't
And some docs can write for and some can't

If it's through pharmacy side the cost could be higher
DS is not on remicade any more
But something to check on before open enrollment ends for next year

 

[cassimw]

Thanks everyone! My insurance co (Aetna) will also be billing under medical (I found this out the other day when I called to be sure it was covered. I didn't even understand that that could be done! But it's as you say, the doctor's office where my daughter goes has an infusion center and they are giving her the meds there. I guess the office gets it from the specialty pharmacy.

This is all really good information everyone. Thanks so much! I feel a bit better about the 6 month thing now.

 

[Mehita]

Be aware
I just read on another forum
Bcbs of mass is changing from covering it under medical to requiring patients get it from specialty pharmacy and then sent to the facility to give it which some infusions centers allow and some don't
And some docs can write for and some can't

If it's through pharmacy side the cost could be higher
DS is not on remicade any more
But something to check on before open enrollment ends for next year

Do you have a link, MLP? We have BCBS and that news scares me.

We've never called insurance for pre-approval for anything in the last seven years... just sort of did what was needed at the time and haven't had any issues. BCBS has covered their portion of it all. Maybe our hospital is doing all the talking for us?

You'll really want to look in to Remistart. There is a form for your GI to fill out, so you'll need to remember to bring it the next time you see him/her.

 

[Jmrogers4]

Mehita I have Regence blue shield and we received a letter stating that they were changing to getting from the pharmacy and having it done at infusion center (Walgeens I think it was) but that we would get another letter if it affected us. We never received another letter and got the approval for another year of Remicade. We (GI and myself) thought that maybe it was because he is pediatric and different rules apply.

 

[Madhu]

My husband has Aetna and he was also pre-approved for 6 months. I asked his infusion centre about future approvals and they said they would take care of it and will keep extending the coverage as and when needed