Remicade (Infliximab) and Insurance in the US?

[kdgh]

Hi all, my doctor wants to prescribe Remicade but the pre-authorization forms make me worried that 1) Behcet's is not covered (because only 5 other illnesses are included on the form), and 2) It may be covered under pharmaceutical (expensive!) rather than medical (where they will do the injections in the office). Oh, it also asks if "the patient has been treated with the preffered TNF antagonists, Enbrel or Humira" and if those have failed. I have not tried those (and we've determined my best option for my symptoms if Remicade so I don't want to try those) but is there any way around that question?

Basically, does anyone have experience getting Remicade approved? If so, I would love to know if there is anything I can do to make sure things go smoothly.

Thank you very much!

[chlovak]

Hi kdgh,

I realize your post is a month old, so hopefully your insurance has already approved Remicade for you! However, if not-- you're certainly not alone, unfortunately. I was fortunate to have Remicade approved when I was first diagnosed as a teenager, and it worked wonderfully for several years. I know that my rheumatologists had to petition on my behalf in order to have it approved, but thankfully they were successful. I have no idea what the deciding factors were, but the one thing that's been clear throughout my 10 years with Behcet's is that having a rheumatologist who's willing to petition and argue your case to the insurance company is vital. So, if it isn't approved on the first try, ask your doctor if he/she will petition the decision.

My current rheumatologist seems to have an even better strategy, however: she added a diagnosis of inflammatory arthritis (which, she says, I have-- whether it's caused by Behcet's or not) to my case, and uses that diagnostic code (rather than Behcet's) when submitting pre-authorization forms to my insurance. Not surprisingly, this ensured that both Enbrel and Humira were approved immediately. I can't say whether this strategy is widely practiced, or if your doctor would be willing to try it, but it might be worth mentioning.

Good luck!

[kdgh in reply to chlovak]

Thank you! So I brought this up with my new rheumatologist (recently moved) and she didn't want to do that because she couldn't see RA evidence in my joints, even though my RF blood tests sometimes come up as positive (rare in BD?) so right now I started Humira bc insurance denied Remicade until I tried Humira first...but now the dosing issue is a problem, as the rheumatologist only feels comfortable prescribing 40 mg every two weeks but since I now have a diagnosis of Intestinal BD and the recommended dosage is 160, then 80, then 40, she wants me to get a gastroenterologist to prescribe that. What is your dosage?

[chlovak in reply to kdgh]

I'm taking 40mg weekly-- currently on week two. The pharmacist remarked that it was an "unusual" dosing schedule, but my rheum's nurse said the dosing always depends on symptoms/severity and bloodwork (my white cell counts are through the roof). You're definitely right that testing positive for RF is uncommon in Behcet's, so I am a bit surprised that your rheumatologist didn't consider that enough to warrant an additional RA dx. How long will it take to get in to see the gastroenterologist, and does your rheumatologist want you to start the Humira now regardless? I'd think that since Humira still isn't FDA approved to treat Behcet's (so it's off-label), there aren't necessarily established guidelines for dosing & schedule yet for Behcet's... I know the dosing you mentioned for GI involvement is what's standard for Crohn's, however, so the same should be true for intestinal Behcet's, depending on the extent/severity of your symptoms. For what it's worth, when I was first diagnosed I had severe intestinal involvement, but this didn't seem to affect what or how much of anything my rheumatologists prescribed. Anyway, it's great that your insurance approved Humira, and I hope you can start it soon! It's too early to know for sure how well it's working for me, but so far (after just two doses), my joint pain is significantly improved and I've had no new mouth or genital ulcers... so (fingers crossed), I'm pretty optimistic about it!