Reply To: Rituximab

Rituxan is a genetically engineered monoclonal antibody that targets a specific protein, known as CD20 found on the surface of normal and malignant B-lymphocytes. Insurance companies have very specific guidelines covering “medical necessity” for this drug. Here is an example of the guidelines from my ex-insurance company in California:
https://www.anthem.com/medicalpolicies/policies/mp_pw_c103932.htm
And from Oregon:
http://www.regencerx.com/learn/priorAuth/oregonPriorAuth.html

Guidelines vary by insurance company and State. Your doctor must make a case that addresses the specific guidelines developed by your Ins co. Who are you insured with? Do you have their policy for Rituxan?

Once you’re request for the drug has been officially denied, you can take it through the grievance-appeal process. I did this twice with BCCA and won. The State is usually on the side of the patient in a grievance case.

Hope this info helps you Karen. It’s terrible how much control Ins co’s have on our health and well being these days. I wish you a speedy authorization process and hope you get started on Rituxan soon!