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Released on Feb 4, 2021

What you need to know about UnitedHealthcare’s Remicade coverage change

Effective February 1, 2021, United enacted a policy to remove Remicade as a preferred product as announced in its Medical benefit specialty drug update bulletin. However, United has made clear that patients will not be required to switch until the date of their prior authorization renewal. As per its policy, “UnitedHealthcare will honor all approved prior authorizations on file until the end date on the authorization or the date the member’s eligibility changes. Providers don’t need to submit a new notification/prior authorization request for members who already have an authorization…”

After conversations with our societies’ physician experts, United agreed to modify its coverage policy to allow pediatric patients 16 years of age and younger and currently on Remicade to remain on Remicade if that is the recommendation of the treating physician.

Adult patients meeting the following conditions may be allowed to remain on Remicade, but will require the prescribing provider to request a review and a determination will be made on a case-by-case basis:

  • Adult patients currently on induction of Remicade for less than 18 months will not be required to switch.
  • Adult patients who are having a flare of active disease, and hence are not stable, will not be required to switch.

United shared it is educating all of its medical directors as quickly as possible about these changes and will develop new member education to more clearly communicate the new policy to patients, many of whom were confused by wording of the original notice.

Please contact your specialty society staff if you are encountering problems with the prior authorization process, your patient was switched without your consent or your request to keep your patient who meets the above criteria on Remicade has been denied. United has asked us to report any problems so it can continue to refine its communications and efforts as needed.


ACG
Brad Conway
bconway@gi.org

AGA
Leslie Narramore
Lnarramore@gastro.org

ASGE
Lakitia Mayo
lmayo@asge.org

NASPGHAN
Camille Bonta
cbonta@summithealthconsulting.com