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Insurance Won’t Approve Remicade Every 6 Weeks

Update – On Remicade for 9 months now. Working great but not lasting full 8 weeks in between infusions. Blue Shield will not allow me to receive infusions any more than every 8 weeks!

My Current Story:

I’ve had UC since 2003….been on Remicade since January 2011. Been going great – pretty much symptom free. My problem is the 8 week infusion cycle is too long for me. My body starts to go back to its old ways around week 5 1/2…..more frequent trips to the bathroom, looser stools, gut pain, nausea, fatigue, etc… My GI said we needed to move it up to every 6 weeks so I can stay on the up side of my disease. I was very excited with that news. Well – that was almost 7 weeks ago! I have since been batting with blue shield to approve it! I have been through one audit process (that yielded a big fat NO) and now am starting a second one!

Is there anyone out there that has had to have their infusion cycle increased? And did you have any trouble with your insurance? Any suggestions or new routes to try?

 My medications:

Remicade 10mg per kg every 8 weeks
Lialda
Methotrexate

Submitted in the Colitis Venting Area by Megan




7 Responses to Insurance Won’t Approve Remicade Every 6 Weeks

  1. Adam
    Adam October 14, 2011 at 4:24 am #

    How are things going with the second audit process for your next infusion? is there any good news to report? I sure hope so, take care, adam

    • Megan October 18, 2011 at 4:28 pm #

      No luck! They denied me again! I now have my GI and general doctor working directly with blue shield. My general doctor is thinking of reporting blue shield to the insurance board for not approving what a doctor is recommending. I don’t know the specifics yet….but hey…..if it gets me my meds every 6 weeks I’m good with it! On a good note – I made it to the 8 week mark and got my infusion and am feeling better again – eating normal meals and all! :)

      • Adam
        Adam October 18, 2011 at 4:40 pm #

        Hey Megan,
        I’m sorry they gave the denial again…But heck yeah if you can report them and they change their ways, isn’t that what insurance is for anyways??? If you have an insurance agent who helped you with your insurance, maybe you could contact them and see if they can throw their elbows around on your behalf along with your doctor. I hope the remicade continues to flow for you, and gives you some good days ahead of normal living!! keep it up Megan!

  2. Adam
    Adam October 14, 2011 at 4:26 am #

    I myself don’t have any experience with it, but i have heard of others who had shorter time intervals between infusions approved, so I wish you the best of luck.

  3. Mary November 6, 2011 at 8:43 pm #

    I have been on Remicade for 3 yrs now to treat my Crohn’s disease. Within 3 infusions my doctor had me at highest dose allowed and shortly thereafter she increased the frequency from 8 to 6 weeks. Remicade is super expensive plus yoh have to add in the nursing costs for the infusion. I have Kaiser and I have never had a problem with them dènying care that my doctor orders because of cost? Do you have Kaiser in your area? I hope this helped.

  4. Judy November 25, 2011 at 6:26 pm #

    BC/BS of Illinois approved my Remicade 10mg/kg q 6 weeks without any fuss. My problems is that I don’t think I need that strong of a dose, my my GI doesn’t want to try to back off.

  5. Irene November 27, 2011 at 2:33 am #

    Look up Johnson & Johnson patient Assistance foundation they maybe able to help you cover the cost of the infusion.
    They help people with or without insurance pay for there infusions.
    1-800-652-6227

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