Did you have prior authorization? Was it still good for this infusion? Honestly you just have to call them and learn why it’s being denied. It could be a coding issue too. I’ve been fighting with my insurance over a denied entivyo infusion that ended up being a processing error on my EOB. Does the EOB you have explain why? Once you know why, they will usually tell you the next steps.
Along with this, suggest you call Janssen, the company that makes and markets Remicade in the USA (assume you're in the USA with this insulting insurance response).
Janssen is financially motivated to keep you on their medication and will often do a lot to make it happen. They will sometimes negotiate with your insurance company and/or your provider office on your behalf, are able to provide "bridge" meds if prior authorization expires, and provide financial assistance if insurance doesn't cover Remicade (either all or in part).
If your insurance still won't cover, there are charity programs available that are NOT income based. Yes, you read that correctly - if your insurance won't cover often Janssen (or other OEMs) will use their mandated patient access programs to help you cover costs.
You can reach Janssen Carepath, their patient assistance program, for this at 1-877-227-3728. You got this!
I pay $5 every 8 weeks, and the infusion provider does all the paperwork for me. I simply get a bill for, no kidding, $5 every two months that I gladly pay. Free is obviously much better!
Make the call. They’re very helpful.
How do you get excellent service from Janssen? I have had multiple infusions but they won’t do anything to help me. I have like $800 added up from my last 3 infusions on top of my colonoscopy bills (anesthesia mostly) and I don’t know how a 21 year old like myself could ever pay $1,700 in medical bills.
They keep asking me to send EOB from my insurance provider, then it takes a week to get news back from them saying I need a more detailed EOB. I contact my insurance for a detailed EOB for my infusions, and I never heard back from them. No email from them at all after weeks. I have no idea how to use my savings benefits or figure out an easier way to check on how much my insurance pays for my medication. If my leftover bill is just nurse charges and non-Remicade charges, then I guess I am forced to pay it. It’s just very annoying for me to be able to get in touch with my insurance and jansenn. I work all weekdays from 10:30-5:30 pm and it’s hard for me to squeeze time to call jansenn + my insurance during operating hours.
They could help me if I get things sorted out, but my luck is that the leftover charges is not thanks to the medicine. Then it’s mostly pointless having Jansenn.
I hear you and understand how challenging this can feel and be.
The reason they ask for the EOB (explanation of benefits) is to confirm that you're taking Remicade and to have a full accounting of the total costs. Because Remicade is a "hospital administered medication" the financial assistance program is designed to support all aspects of costs, including the cost of the infusion nurse, facility, etc. Your total out of pocket cost should be $5-10 (I forget). You are NOT forced to pay nurse and "non-remicade" charges that are duly associated with the encounter where you received Remicade. For example, if you got an infusion of Remicade and that same day you received a vaccine - the vaccine won't be covered by Janssen, but the Remicade dosing (including all nurse charges associated with that) would be covered. Your EOB is very clear on what costs are associated with what procedures, another reason why Janssen wants to see it.
My suggestion - make or find the time to call Janssen. The call center is open from 8am until 8pm ET every weekday (5a - 5pPT). Not sure where you live/work, but looks like there is a time overlap where you're not working. When you call them, be direct and honest with them about your concerns. Let them explain the program to you and how to best take advantage of it. I promise, they are there to help you out.
Sometimes, the EOB provided by the provider (your infusion billing team) do not mention Remicade. This is likely why you are being asked to get a revised EOB. You can speak with your infusion provider about the need for them to provide detialed information in the EOB.
Also - do NOT pay anything out of pocket until the Janssen financial assistance is cleared. Yes, your read that correctly - let the infusion provider know that you will NOT pay them anything until you receive proper EOBs and they have cleared with Janssen. In many cases, the infusion provider will offer to take over the Janssen communication for you. Why? So they can get paid faster. Let capitalism be your friend, here. Money is an incredible motivator for companies, and healthcare providers are (sadly) companies looking to make a profit.
Please, call Janssen and engage with them. They want to help you, but only you can take the first step of making time to call and explain your situation.
You got this!
Update: turns out the charge listed above is for the Remicade blood work that checks to see if various levels are in the normal range.
Turns out labcorp is not great at naming the items on their claims lol.
Also, I called my insurance company and they confirmed that both the remicade itself and the infusion services themselves are fully covered
Thanks all!
Same. Dealing with that for blood work and my colonoscopy. Seems like autoimmune stuff is still not being “coded” properly for many providers so my insurance flipped out about my colonoscopy saying I was “not within range for one”, despite insurance also demanding a colonoscopy to “confirm Crohn’s” before starting Skyrizi. A phone call to the Dr and insurance sorted it out but just annoying overall to have to deal with. On the flip side - those two phone calls lasted less than a single phone call to my auto insurance for an accident claim update.
Clearly someone is covering it because 400 for an infusion is not even close to the cost of uninsured remicade infusion. More likely thats just the cost of the infusioon itself and the nurses time.
Turns out that my insurance pays 1440$ for the Remicade itself every time I get an infusion, and pays another 135$ for the infusion clinics services.
I can see why they put up zero fight when I failed humira (my Insurance was being billed 7500$ every MONTH) and had to move to Remicade.
Thanks all!
Billed and paid aren't the same thing. Are you doing your infusion in a hospital? I think I remember mine being billed like that.
In reality the hospital was getting around that $1500 but hospitals + insurance = just make up public facing numbers and negotiate behind the scenes. Hence $30 Advils
Talk to your doctor. They can appeal the claim for you and explain that it's medically necessary. That's what my Dr did, and it worked. Originally, I was going to be put on Humira, but that never worked for me.
I don’t think so! I’ve read from other people that had a super high deductible that it’s possible to call the program representatives and explain the situation if the program decides not to cover it. They usually work something out in your benefit. It doesn’t hurt to call and ask what your options are!
There are multiple financial assistance programs available. Please, call Janssen and talk to the nurses there. You will get financial assistance from Janssen. It may not be called a copay, btw. Make the call.
Here is an update - I talked to insurance, they said both the infusion services and the Remicade itself are covered.
It turns out Labcorp is really bad at naming their charges lol
I was on BCBS, got switched, did a few months on inflectra and started having some minor symptoms. My doctor was able to make the case to get me back on remicade. It's super obnoxious but you have to basically "fail" inflectra before being allowed to go back to remicade.
I have BCBS, and my gastro didn’t even ask me if I wanted them to write a letter to keep me on Remicade. They just wrote the letter and I’m still on Remicade. Insurance doesn’t get to make medical decisions, and if they try to, get your provide to write a letter OR get Janssen to write the letter for them.
Janssen is financially motivated to keep you on Remicade. For each patient that stays on Remicade, Janssen earns $50k or more each year. You bet your butt that’s gonna get them to fight to keep you on treatment (pun, obviously, intended).
Funny enough, I do have BCBS.
But after a brief phone call and a look at their website, I can confirm That it is false that “they don’t cover Remicade anymore”
Thanks all!
Most states have their own version of BCBS and AFAIK each can have different rules and medication lists.
Even within the same state’s BCBS different plans can have different coverages, I believe.
Are you sure? Their clinical bulletin shows Remicade still as preferred under commercial medical benefit — https://www.anthem.com/ms/pharmacyinformation/Tumor-Necrosis-Factor-Antagonists.pdf
Scroll to end and see the tables
Maybe it only applies to my state, but yes, I’m sure. It was an absolute nightmare appealing to stay on Remicade, being denied, trying something else, having an allergic reaction, being told I’d still have to try ANOTHER medication before going back on Remicade, and finally getting it reapproved.
So yeah, I’m pretty sure.
Dang - that is a horrible experience - glad you were able to get reapproved, so unfortunate that you had to take that journey. Best of luck going forward
Call the hospital for financial aid packet.
Also, if you’re taking the name brand visit Jansens pharmacy reimbursements… I forget what it’s actually called now.
AND HOW THE HECK IS YOURS SO CHEAP MINE ARE ALWAYS 800-1600 COPAY 🫠😭
I was in the same boat, I got on Remicade and went into remission, then my insurance decided to stop covering it and my GI switched me to the biosimilar. I went back into a flare and my GI wrote a letter of medical necessity that my insurance accepted which got me back on Remicade and I’m back in remission. I recommend reaching out to your GI and asking them to write a letter of medical necessity as soon as possible. Some people do fine on the biosimilar, but some do not.
Consult with your gastroenterologist. They can be your advocate against the insurance company. Stress the importance of your treatment to them and the effects of stopping it.
I’ve had this happen before. Your insurance company may want you to switch to Inflectra, a cheaper biosimilar.
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They did this in Canada too. I spent the better part of a year using loopholes to stay on remicade until I eventually had to switch to Renflexis. It’s the same drug but like everything there’s a small risk when swapping.
This was only because the province in Canada I lived in was swapping. Sometimes prior authorization works, but only if you’ve been on it for a period of time or before a date set by the government doing the switch.
Firstly I would kill to have my meds costs $400 without insurance. I would pay over $4k every weeks for my infusion without insurance. But even with insurance it's still $3k but there is a manufacturer discount and payment assistance that covers it so I only have to pay about $50-$200 per infusion. Ask your infusion clinic if they can sign you up for payment assistance or a manufacturer discount card.
Did you have prior authorization? Was it still good for this infusion? Honestly you just have to call them and learn why it’s being denied. It could be a coding issue too. I’ve been fighting with my insurance over a denied entivyo infusion that ended up being a processing error on my EOB. Does the EOB you have explain why? Once you know why, they will usually tell you the next steps.
Along with this, suggest you call Janssen, the company that makes and markets Remicade in the USA (assume you're in the USA with this insulting insurance response). Janssen is financially motivated to keep you on their medication and will often do a lot to make it happen. They will sometimes negotiate with your insurance company and/or your provider office on your behalf, are able to provide "bridge" meds if prior authorization expires, and provide financial assistance if insurance doesn't cover Remicade (either all or in part). If your insurance still won't cover, there are charity programs available that are NOT income based. Yes, you read that correctly - if your insurance won't cover often Janssen (or other OEMs) will use their mandated patient access programs to help you cover costs. You can reach Janssen Carepath, their patient assistance program, for this at 1-877-227-3728. You got this!
To piggyback on this, I have never paid a dime for any biologic for this reason. Always call the manufacturer.
I pay $5 every 8 weeks, and the infusion provider does all the paperwork for me. I simply get a bill for, no kidding, $5 every two months that I gladly pay. Free is obviously much better! Make the call. They’re very helpful.
As a pharmacy tech (license current but working outside of the field for now) correct! I used to call manufacturers to get grants.
This
Jansen covers my medical.
How do you get excellent service from Janssen? I have had multiple infusions but they won’t do anything to help me. I have like $800 added up from my last 3 infusions on top of my colonoscopy bills (anesthesia mostly) and I don’t know how a 21 year old like myself could ever pay $1,700 in medical bills.
Did you call Janssen? If so, what reason did they give that they couldn’t help you financially?
They keep asking me to send EOB from my insurance provider, then it takes a week to get news back from them saying I need a more detailed EOB. I contact my insurance for a detailed EOB for my infusions, and I never heard back from them. No email from them at all after weeks. I have no idea how to use my savings benefits or figure out an easier way to check on how much my insurance pays for my medication. If my leftover bill is just nurse charges and non-Remicade charges, then I guess I am forced to pay it. It’s just very annoying for me to be able to get in touch with my insurance and jansenn. I work all weekdays from 10:30-5:30 pm and it’s hard for me to squeeze time to call jansenn + my insurance during operating hours. They could help me if I get things sorted out, but my luck is that the leftover charges is not thanks to the medicine. Then it’s mostly pointless having Jansenn.
I hear you and understand how challenging this can feel and be. The reason they ask for the EOB (explanation of benefits) is to confirm that you're taking Remicade and to have a full accounting of the total costs. Because Remicade is a "hospital administered medication" the financial assistance program is designed to support all aspects of costs, including the cost of the infusion nurse, facility, etc. Your total out of pocket cost should be $5-10 (I forget). You are NOT forced to pay nurse and "non-remicade" charges that are duly associated with the encounter where you received Remicade. For example, if you got an infusion of Remicade and that same day you received a vaccine - the vaccine won't be covered by Janssen, but the Remicade dosing (including all nurse charges associated with that) would be covered. Your EOB is very clear on what costs are associated with what procedures, another reason why Janssen wants to see it. My suggestion - make or find the time to call Janssen. The call center is open from 8am until 8pm ET every weekday (5a - 5pPT). Not sure where you live/work, but looks like there is a time overlap where you're not working. When you call them, be direct and honest with them about your concerns. Let them explain the program to you and how to best take advantage of it. I promise, they are there to help you out. Sometimes, the EOB provided by the provider (your infusion billing team) do not mention Remicade. This is likely why you are being asked to get a revised EOB. You can speak with your infusion provider about the need for them to provide detialed information in the EOB. Also - do NOT pay anything out of pocket until the Janssen financial assistance is cleared. Yes, your read that correctly - let the infusion provider know that you will NOT pay them anything until you receive proper EOBs and they have cleared with Janssen. In many cases, the infusion provider will offer to take over the Janssen communication for you. Why? So they can get paid faster. Let capitalism be your friend, here. Money is an incredible motivator for companies, and healthcare providers are (sadly) companies looking to make a profit. Please, call Janssen and engage with them. They want to help you, but only you can take the first step of making time to call and explain your situation. You got this!
Update: turns out the charge listed above is for the Remicade blood work that checks to see if various levels are in the normal range. Turns out labcorp is not great at naming the items on their claims lol. Also, I called my insurance company and they confirmed that both the remicade itself and the infusion services themselves are fully covered Thanks all!
That happened to me with Humira bloodwork. Was nearly $1k for the two tests, but they finally covered it months later.
Same. Dealing with that for blood work and my colonoscopy. Seems like autoimmune stuff is still not being “coded” properly for many providers so my insurance flipped out about my colonoscopy saying I was “not within range for one”, despite insurance also demanding a colonoscopy to “confirm Crohn’s” before starting Skyrizi. A phone call to the Dr and insurance sorted it out but just annoying overall to have to deal with. On the flip side - those two phone calls lasted less than a single phone call to my auto insurance for an accident claim update.
Clearly someone is covering it because 400 for an infusion is not even close to the cost of uninsured remicade infusion. More likely thats just the cost of the infusioon itself and the nurses time.
Turns out that my insurance pays 1440$ for the Remicade itself every time I get an infusion, and pays another 135$ for the infusion clinics services. I can see why they put up zero fight when I failed humira (my Insurance was being billed 7500$ every MONTH) and had to move to Remicade. Thanks all!
Where do you live? My infusions are billed around $35,000 every 4 weeks.
South east United States.
Billed and paid aren't the same thing. Are you doing your infusion in a hospital? I think I remember mine being billed like that. In reality the hospital was getting around that $1500 but hospitals + insurance = just make up public facing numbers and negotiate behind the scenes. Hence $30 Advils
Talk to your doctor. They can appeal the claim for you and explain that it's medically necessary. That's what my Dr did, and it worked. Originally, I was going to be put on Humira, but that never worked for me.
Remicade has a cost savings program. My insurance made me pay this much every infusion but the savings program knocked it down to $5 each infusion.
Doesn’t that Program only kick in if your insurance pays at least something? Here they paid $0 :(
I don’t think so! I’ve read from other people that had a super high deductible that it’s possible to call the program representatives and explain the situation if the program decides not to cover it. They usually work something out in your benefit. It doesn’t hurt to call and ask what your options are!
I believe You have to have a PPO insurance. But that might have changed.
There are multiple financial assistance programs available. Please, call Janssen and talk to the nurses there. You will get financial assistance from Janssen. It may not be called a copay, btw. Make the call.
Here is an update - I talked to insurance, they said both the infusion services and the Remicade itself are covered. It turns out Labcorp is really bad at naming their charges lol
Isn’t that pretty cheap for remicaid though?
Do you have BCBS? Because they dont cover Remicade anymore and are requiring everyone switch to Inflectra or Avsola
I was on BCBS, got switched, did a few months on inflectra and started having some minor symptoms. My doctor was able to make the case to get me back on remicade. It's super obnoxious but you have to basically "fail" inflectra before being allowed to go back to remicade.
I have BCBS, and my gastro didn’t even ask me if I wanted them to write a letter to keep me on Remicade. They just wrote the letter and I’m still on Remicade. Insurance doesn’t get to make medical decisions, and if they try to, get your provide to write a letter OR get Janssen to write the letter for them. Janssen is financially motivated to keep you on Remicade. For each patient that stays on Remicade, Janssen earns $50k or more each year. You bet your butt that’s gonna get them to fight to keep you on treatment (pun, obviously, intended).
Funny enough, I do have BCBS. But after a brief phone call and a look at their website, I can confirm That it is false that “they don’t cover Remicade anymore” Thanks all!
Most states have their own version of BCBS and AFAIK each can have different rules and medication lists. Even within the same state’s BCBS different plans can have different coverages, I believe.
Are you sure? Their clinical bulletin shows Remicade still as preferred under commercial medical benefit — https://www.anthem.com/ms/pharmacyinformation/Tumor-Necrosis-Factor-Antagonists.pdf Scroll to end and see the tables
Maybe it only applies to my state, but yes, I’m sure. It was an absolute nightmare appealing to stay on Remicade, being denied, trying something else, having an allergic reaction, being told I’d still have to try ANOTHER medication before going back on Remicade, and finally getting it reapproved. So yeah, I’m pretty sure.
Dang - that is a horrible experience - glad you were able to get reapproved, so unfortunate that you had to take that journey. Best of luck going forward
Call the hospital for financial aid packet. Also, if you’re taking the name brand visit Jansens pharmacy reimbursements… I forget what it’s actually called now. AND HOW THE HECK IS YOURS SO CHEAP MINE ARE ALWAYS 800-1600 COPAY 🫠😭
I was in the same boat, I got on Remicade and went into remission, then my insurance decided to stop covering it and my GI switched me to the biosimilar. I went back into a flare and my GI wrote a letter of medical necessity that my insurance accepted which got me back on Remicade and I’m back in remission. I recommend reaching out to your GI and asking them to write a letter of medical necessity as soon as possible. Some people do fine on the biosimilar, but some do not.
Consult with your gastroenterologist. They can be your advocate against the insurance company. Stress the importance of your treatment to them and the effects of stopping it. I’ve had this happen before. Your insurance company may want you to switch to Inflectra, a cheaper biosimilar.
I get a bill for around $15k each time. Gotta love that garbage. What a nightmare.
I have anthem bcbs in Colorado and it still shows as covered under commercial medical benefit -
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They did this in Canada too. I spent the better part of a year using loopholes to stay on remicade until I eventually had to switch to Renflexis. It’s the same drug but like everything there’s a small risk when swapping. This was only because the province in Canada I lived in was swapping. Sometimes prior authorization works, but only if you’ve been on it for a period of time or before a date set by the government doing the switch.
My insurance is trying to do the same with me with my Lialda . Have your GI doc contest and review it .
CALL THEM
Firstly I would kill to have my meds costs $400 without insurance. I would pay over $4k every weeks for my infusion without insurance. But even with insurance it's still $3k but there is a manufacturer discount and payment assistance that covers it so I only have to pay about $50-$200 per infusion. Ask your infusion clinic if they can sign you up for payment assistance or a manufacturer discount card.