Getting Xeljanz approved by Insurance

Has anyone else had a ridiculous time getting Xeljanz approved by insurance? I have been trying since September 1st and what I have experienced is actually comical at this point. I was denied at first.... pharmacy filed an appeal. Appeal was finally heard around mid October and I was approved for 20 mgs... however my doctor wrote a prescription for 5 mg pills and they will not allow more than 2 pills a day...Tried for 10mgs 2 x a day.. that was denied as well. Appealed that.. back to the drawing board and now they are allowing 5 mg pills but are " processing this through their system". I spend at least an hour on the day with Anthem and Accredo.

Ditto Keith. Your gastero office should have a nurse who helps with this process and does all of the needed paperwork.

You can call your insurance and ask what their policy is for xeljanz. For example, do you have to 1st fail one other anti-tnf medicine (humira/remicade/smponi) BEFORE xeljanz is allowed? That's fairly common with new biologics (xeljanz and entyvio as examples).

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Moderator Ulcerative Colitis
John, 40, UC Proctosigmoiditis
Rx: Remicade @5mgs/kg/6wks; daily 75mgs 6MP, 4.8g generic-Lialda, and rowasa
Wow you look great, did you loose weight? Yeah, I lost 20 pounds in a month through this great new program called IBD, you should try it! I wasn't hungry, all I had to do was be doubled-over in pain with frequent diarrhea!

I hate it for you Talli… I'm awaiting insurance approval for Entyvio now. It's such a shame that patients are being 'punished' due to the insurance companies policies. As others mentioned, your doctor's office should have someone who deals with the insurance and prior-authorizations. On the comical side...I recently was given a prescription for 1 pill, each night for 30 days. Insurance denied it. Doctor wrote new one for 1 pill every 6 hours for 7 days...insurance approved it quickly. It's a shame that insurance companies are now practicing medicine...in MY opinion. Hang in there and try to be patient....it's sure not pleasant in the meantime for many things though. Good luck and hopefully, you'll get approved soon.

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diagnosed in 1997. meds: triamterene HCTZ, soon to begin Simponi , Lialda 1200mg 1x a day,Hyoscyamine sulfate odt 0.125 4-6 hours as needed,Omeprazole 40mg 1 capsule a day,Latanoprost op 0.005% 1 drop each eye, Potassium 90mg 1 x a day

Yup. BCBS, Denied once - had to have a doctor's appointment... Doc wrote a "he's doing great on Xeljanz samples" progress report and sent those notes and we've now been waiting on the appeal. Doc said he'd do a doctor to doctor discussion with insurance if this 1st appeal fails. Having failed Remicade, despite Xeljanz working like a champ, they want me to do Humira or Entyvio and fail one of those before considering... probably b/ those drug companies have biiiig deals with the insurance companies... it's frustrating and.. yes, comical

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01/16: Given Clindamycin for staph infection in stye that kicked off this whole UC fun; C-Diff twice; Flagyl then Vancomycin 250mg fixed
2/18: Severe Pancolitis confirmed - Mesalamine 1.2gm + Uceris 9mg 1x day ok
4/18: First flare; Pred 40mg stepdown no good
9/18: 6 Remicade treatments done - no good, unable to lower beyond 30-40mg Pred
10/10/18: Starting Xeljanz 10mg twice day & try to taper Pred

nealzy said...
Yup. BCBS, Denied once - had to have a doctor's appointment... Doc wrote a "he's doing great on Xeljanz samples" progress report and sent those notes and we've now been waiting on the appeal. Doc said he'd do a doctor to doctor discussion with insurance if this 1st appeal fails. Having failed Remicade, despite Xeljanz working like a champ, they want me to do Humira or Entyvio and fail one of those before considering... probably b/ those drug companies have biiiig deals with the insurance companies... it's frustrating and.. yes, comical

If there is a process that was supposed to be followed and your GI didn't do it then who's fault is it? There is more clinical data on Humira and Entyvio.

So I tell my GI that I'd like to try Stelara every 4 weeks (45 mgs) instead of 8 weeks (90 mgs) because I feel like my symptoms are better during 2-6 week mark. He tells me that we probably can't get that covered because there is not enough clinical data on it. He's not even sure that it would work like I think it would because there is no clinical data on it.

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Keith

DX'd with Severe Pancolitis June 2005
Previous Meds: 5ASAs, Predisone, 6-MP. Remicade, Humira, Simponi, Cimzia & Cyclosporine
3-step J-Pouch surgery: 2013 & 2014

Current Condition: Chronic Pouchitis -- Not as bad as I thought it would be
Current Meds: Stelara
Total Hip Replacement: 12/16 -- Thanks Prednisone!!!
www.healingwell.com/community/default.aspx?f=38&m=3755226

noodlesnoodles I'm in Texas. The point isn't more clinical data IMHO. GI had samples, I tried it and noticed improvement after 3 days. Now 5 weeks into it, I'm nearing remission, so... why do I need to take a step backward and try something that may not work when I have something that does work?

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01/16: Given Clindamycin for staph infection in stye that kicked off this whole UC fun; C-Diff twice; Flagyl then Vancomycin 250mg fixed
2/18: Severe Pancolitis confirmed - Mesalamine 1.2gm + Uceris 9mg 1x day ok
4/18: First flare; Pred 40mg stepdown no good
9/18: 6 Remicade treatments done - no good, unable to lower beyond 30-40mg Pred
10/10/18: Starting Xeljanz 10mg twice day & try to taper Pred