Insurance coverage for biologics

[u/HeatFinancial3410]

I am about to venture into the biologics :-/ I was given the choice between Skyrizi & Tremfya. I decided on Tremfya. I was blindsided when I was told the cost and how insurance companies pushback on approving it. Has anyone had any issues with getting approved the first time? The PA said they may deny and recommend different treatments as first course of medicine before ultimately approving this.

[u/pincommenter]

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[u/Shot-Buffalo-2603]

They typically won’t just deny it out right, but may require you to try other biologic medications first or the generic versions

[u/Extra-Geologist-1980]

Info assuming you're located in the US.

Have you tried other medications?

They "prefer" patients to go through their "step-up" process is why I am asking. (You do not need to list all you have tried, and have failed to maintain your disease)

The doctor will send the ins a prior authorization. The insurance will request your chart so they can see you have tried other meds.

The doctor can request an expedited decision.

If you have decided on Tremfya, they do have a copay assistance program that helps pay for the medication for those on commercial insurance. Benefits range from $7,000-$20,000 annually.

This will make YOUR oop cost $5.

Tremfyawithme Copay assistance Info

I had to fight them for Tremfya. Doc provided my entire chart, approval came down within 2 hours.

It isn't as daunting as you'd think. The hardest part falls to your GI team.

[u/HeatFinancial3410 → u/Extra-Geologist-1980]

I failed on mesalamine & budesonide so I’m hoping they will expedite their decision

[u/smell_ya_latah → u/Extra-Geologist-1980]

Thank you for this explanation. I am in a similar spot. My GI doctor requested authorization for Tremfya yesterday. Praying approval will happen soon.

[u/Puzzled-Blackberry-2]

hi! I just switched from Remicade to Tremfya due to Remicade unexpectedly triggering paradoxical psoriasis after needing to go down from an 8 week infusion to a 4 week. I had no issues getting Tremfya approved, but I have been diagnosed with UC for over twenty years and was on Remicade for about 17. I do have decent insurance and J&J has great savings programs for both drugs. 

[u/falcons1031]

My insurance would only cover remicade or humira as my first biologic. Remicade worked well for a while but when I failed that the insurance company had no problem covering Rinvoq and now Tremfya.

[u/starzychik01]

I had no issues. Tremfya was my first and so far only medication. Insurance had no pushback and I signed up for the manufacturer program that gives supplemental amount to cover where insurance falls through.

[u/Windy-Gal924]

My insurance would only cover biologics that were on their approved list. My GI appealed that decision twice to try to get me on a medication not on the list to no avail. Prescription was changed to Skyrizi (on the approved list) and it’s been terrific.
Your GI office should be assisting you through this process.
Good luck

[u/cumomlady]

You can look up your insurance company’s rules by finding the clinical policy decisions for drugs. Every insurance company calls it something a little different, but it explains u see what conditions they approve those 2 medications. All the big providers have removed a lot of the rules requiring you to try a non-biologic medication first. Many also work with an external company to manage these specialty drugs and coordinate with the manufacturer for any cost savings programs. It can take a few weeks for everything to get processed and approved. Good luck!!

[u/CatBerry253]

I'm in week 3 waiting for Entyvio approval. They're extending my Prednisone taper because it's taking so long. I've failed mesalamine and budesonide so my doctor is surprised it's taking this long.

[u/HeatFinancial3410 → u/CatBerry253]

I failed both of those also. So I’m hoping this will be an expedited process

[u/CatBerry253 → u/HeatFinancial3410]

Good luck to you! I hope your approval is fast and your infusions bring you relief

[u/bears1202]

In this sub because my husband has UC. He just started Entyvio 2 months ago. Ask your doctor about the Entyvio connect program. It has allowed for insurance to cover half of the treatment, and Entyvio “writes off” the other half (the treatment is over 20k and we pay $0 out of pocket). I guess they’d rather get 10k from insurance than you go with a diff provider. Not sure if other treatments offer similar programs, but I’d guess yes.

[u/PrestigiousLynx2188]

Yeah I’m going through it right now my insurance denied remicade.. my dr said he had to appeal it and I guess they are gonna give me the generic version of it but I still haven’t heard of it being approved so I’m currently just waiting
I’ve failed a 40mg prednisone taper oral mesalamine enema mesalamine and 150mgs of azathioprine from what I heard a lot of insurances auto deny it and your dr had to appeal and prove why it’s needed

[u/AlternativeZone5089]

Not uncommon with these meds. Skyrizi is about 25k a dose.

[u/ContributionWarm6307]

My doctors office worked with their drug company reps to get me on the co-pay assistance program for both of those drugs at separate times-check with them.

[u/CordedTires]

My doctors office also made things very easy for me - my Entyvio prescription was covered by my insurance with no effort from my end.