How did you get your insurance to cover Rituxan?

This topic contains 2 replies, has 2 voices, and was last updated by  cer100 2 months, 3 weeks ago.

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  • #116342

    cer100
    Participant

    I think I’ve read all the insurance and Rituxan posts for CIDP that I could find but missed the answer. IVIG, Steroids, and Plasmapheresis aren’t doing what I need to keep me functional for my CIDP and the neurologist wants to try Rituxan.

    Preauth fron BCBS denied. Peer-Peer review also denied due to no clinical trials…and peer Dr also appeared to have little if any knowledge of CIDP from what I was told. Rituxan is not covered for CIDP in medical policy nor have I found any other BCBS customers getting it covered.

    For those successfully getting insurance coverage regardless of carrier, would you explain what you or your Dr. did or approach and reasoning used?

    Am I also reading correctly that Medicare, which I do not have yet, covers Rituxan for CIDP or did I misread that?

    Thanks so much for any assistance.

    #116351

    Jim-LA
    Participant

    Anthem Blue Cross and their subsidiaries have varying drug approval policies by State.

    It seems State policies can be interpreted differently by different BCBS reviewers too. I had a denial from ABC of California (power wheelchair configurations) that I had to appeal to the DOI and file an official grievance. It took 3-4 months and ABC was instructed to change their ruling in my case. Your State DOI may offer a similar option.

    It appears BCBS has approved Rituximab for other forum members in the past. Please read the following thread started by JoMama:
    https://forum.gbs-cidp.org/forums/topic/help-getting-bcbs-approvial-for-rituxan-treatment-of-cidp

    Have you read your State’s BCBS policy regarding the use of Rituximab? Does it say anything about
    patients with Immunoglobulin G4 (IgG4) Autoantibodies? Does it give you any info that could be used in an appeal through your DOI?

    I was able to get approval for Rituximab from Medicare Part B when given as an outpatient procedure at a medical facility (a division of a center of excellence in my area). In my case, some B-lymphocytes were found to exhibit the antigen CD20 which was the medical necessity info Medicare needed to approve Rituximab treatments. It has put my CIDP/MFS in remission, maybe stopped it altogether (time will tell).

    Best of luck to all who must fight the penny-pinching insurance Co’s!

    #116354

    cer100
    Participant

    Thanks Jim. Yes, I read my bcbs medical policies on Rituxan and CIDP and then I called going through them with my case manager but nothing was there.
    I know they want evidence based medicine but seems like potential cost savings to insurance vs 10 day PlEx every month. There is anecdotal evidence.
    Ill take a look at the post you linked and double check the IGG4 again.
    Neuro was suggesting maybe a different immunosuppressant but Ive also got a cancer I am dealing with and must be cautious with the suppressants.

    edit- I see she was previously on Rituxan with good results. That had to help her appeal.

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