Frequently asked questions

Insurance coverage

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Treatment with REMICADE® is covered by most insurance plans, as well as Medicare and Medicaid. Just remember that coverage policies may vary by insurer, by individual, or even between plans offered by the same insurer.

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Your insurance coverage can vary for many different reasons, including:

  • Whether your doctor is part of your health plan (eg, “in network” vs “out of network”)
  • The location where you get therapy with REMICADE® (eg, doctor’s office, home infusion setting, or hospital outpatient department)
  • The rules for preauthorization or referral forms for visits to outpatient departments or medical specialists

If you have any questions about insurance coverage or reimbursement, you should first call your insurance company or Medicare.

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Medicare carriers and the claims processors for all states cover infusions of REMICADE® in doctors’ offices and hospital outpatient facilities. The traditional Medicare Fee-for-Service Program does not cover infusions of REMICADE® when they are provided by home infusion companies or retail pharmacies.

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Medicaid also covers infusions of REMICADE®, but coverage may be restricted to certain treatment settings or may require precertification.

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Most managed care plans—such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs)—cover treatment with REMICADE®. Managed care plans typically require that you share some of the cost of infusion therapies. In general, these plans are likely to require precertification and completion of referral forms for specialist care. They may also limit the choice of providers from whom you may obtain treatment.

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These plans usually cover therapy with REMICADE®. Typically, these insurance plans offer coverage for a wider range of services, but with a higher level of co-payment than a managed care organization. Precertification or prior authorization is usually not required.

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Yes. There are many sources of public and private financial support available to people who need help paying for their medical treatment. In some cases, certain foundations provide support specifically for people who are being treated for a particular disease.

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Some employer and union-provided health insurance policies can continue to provide coverage for you when you are 65 and retired. These plans may coordinate benefits with Medicare. Contact your former employer or union for information on your plan.

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Your new plan may or may not have coverage for REMICADE®. A call can be made to your new insurance plan to determine how they will cover infusions with REMICADE® for you. Once you have elected your new plan, AccessOne® can provide assistance by placing this call to your insurance company and verifying how they will cover REMICADE® and what your out-of-pocket costs will be.

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If you need additional information related to medical coverage for REMICADE®—or if you have other questions or concerns—call AccessOne® at 1-888-ACCESS-1
(1-888-222-3771)
for assistance.

AccessOne®

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At your doctor’s request, AccessOne® will contact your insurance company to determine your benefits eligibility. One of our Care Coordinators will then call both you and your doctor to explain your benefits and potential out-of-pocket expenses.

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Your Care Coordinator will contact you before you begin treatment with REMICADE® to explain your insurance benefits. After that, we’ll only call as often as needed for the services you have chosen.

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If your doctor doesn’t provide infusion services in his or her office, your Care Coordinator can work with your doctor to help locate an infusion site that’s convenient to your home or workplace.

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Call us at 1-888-ACCESS-1 (1-888-222-3771) to let us know, and we won’t contact you further.

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If your Care Coordinator doesn’t have the information you need, you will be referred to someone who does. However, if you have questions about your condition or treatment, you should always consult your doctor first.

RemiStart® Patient Rebate Program

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RemiStart® is a patient rebate program designed to lower rebate out-of-pocket costs for patients with medication deductible, co-payment, or co-insurance expenses in excess of $5 per infusion. Patients can enroll with one step. The RemiStart® rebate card can only be used in the closed network.

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Rebate values are determined on a patient-by-patient basis and are dependent on the patient medication out-of-pocket obligations as verified through an EOB verification. Eligible patients pay $5 per infusion, with up to $20,000 maximum benefit each calendar year.

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No. This program is not designed to provide a rebate to those who have medication out-of-pocket costs less than $5, and these patients will not be able to enroll in this rebate program.

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No, the rebate amount that is credited to the card reflects only the out-of-pocket costs for REMICADE®. The out-of-pocket administration service costs are not used to determine total rebate.

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RemiStart® will send a rebate card to you after enrollment. RemiStart® will provide a rebate for your first infusion following enrollment via a credit to your RemiStart® account. Insurance companies typically send patients their EOBs 2 to 6 weeks after a medical claim has been filed, however, that depends on how soon a claim is filed with your insurance company and how promptly the insurance company processes the EOB. It also depends on how promptly you or your physician forwards the EOB or specialty pharmacy receipt to the program. Thus, there will always be a delay from the time of treatment to the time the rebate is credited to the RemiStart® rebate card.

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Yes. The program does not require that you receive treatment with REMICADE® in your physician's office. However, you will still need to submit your EOB once the infusing healthcare provider (eg, a hospital) has submitted a claim to your insurance company.

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Before the calendar year ends, you will receive information and eligibility requirements for continued benefit in the program.

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The RemiStart® Closed Network is comprised of healthcare provider offices that are able to accept the RemiStart® rebate card.

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