Dee so sorry you are feeling down!! Im sorry wish I knew the answer to your question, I am on medicare and has covered all so far but have never used Rituximab so dunno about that sorry...have never had problems with any others though...I hope someone here can help with that answer for you. Again Im sorry you are down, cause I miss your upbeat posts!! Ive been down myself having BAD stomache problems so test after test after test..So I feel your pain believe me......Your right we need some good belly laughs!!! Big hugs and hope you feel better....jacki

I live on east coast,go to a university Hosp,Dr.medicare is now my primary insur and buy a supp insur. .just went for 2nd ritux infusion today. .since medicare is primary I was told several times that it was not an issue at all. .medicare just pre approves it vs pre auth




which would be the biggest headache for nurse. .if my secondary insur was primary I was looking at least a 3month fight for pre with!

.sorry about mixed up typing but I got up at 5:30am to start Rx at 8:30way too early for my schedule. Had no issues except headache both times. .some of which was worry 1st time and fatigue then came home to hubby and 2yrold grand daug who comes at 2:30. And wants her Nana to read read then play under dining room table. Normally nota problem since i
just get to sit or lay on floor. Hope you get answer soon from drs. Take care everyone

Dee - You are so right. Belly laughs are what we need. Laughter heals all wounds, right? I'll have to find my "You might be an MGer if" post. We have several new folks that could benefit from that humor and might have more to add to it. I'll see what I can do about that. lol

I'm so sorry that you are having such troubles with the medicare issue. Do you have any other issues such as rheumatoid arthritis or Lupus that would qualify you for the infusion? I'm not sure what medicare considers "approved for use" with that drug. It seems to me that medicare paid for it though I haven't done a prior auth in the past for that treatment for MG so I don't know what they deem appropriate or not. I will try to do a bit of research on that and get back to you.

In the mean time please keep your chin up and try to do something that makes you happy at least once a day. It doesn't have to be a lot or even very demanding. Just find one little thing that always puts a smile on your face. I like to watch funny animal and children videos online. It's hard to be depressed with a smile on your face. Big hug to you dear. I hope you feel better and get some answers very soon.
Love,
Angie

OMG!! I just typed a whole lot of stuff and it just disappeared. I hate that... GRRRR

Okay, I'll try again. I agree with you on the belly laughs. I think I'll try to bring back the "You might be an MGer if" post. Especially since there appear to be a lot of newbies lately. It is always good for a laugh and the new members will have an opportunity to add to it too.

As for the Rituxan, I haven't done any prior auths for that for a patient with MG. I'm so sorry that you are going through that issue. Delaying your treatment is never a good thing. Are there any other conditions that you have that this drug would be covered for? I know that it's used to treat patients with other rheumatological issues but I can't remember if they use it for Lupus and Rheumatoid Arthritis, etc. I will try to do a little research and let you know what I find. I have a couple of sites that I use at work that might let me know what medicare deems "off label use". I will let you know if I find anything.

In the mean time please keep your chin up and try to find something that makes you happy every day. I like to watch funny videos online. It's hard to be depressed with a smile on your face.

I hope you feel better soon and that you get your treatment asap. Big hugs to you my friend!!
love,
Angie

The only information that I could find is printed below. It basically says that they don't cover anything but the diseases/conditions list and MG is not among them. It specifies below all of this stuff that MS is not approved as it has not been done in a true "Trial" setting and therefor not approved for use. If that's the case then I doubt that they would cover it for the treatment of MG. Sometimes if it is not approved through conventional methods you can have the doctor do what's called a "Peer to Peer Review" in which your doctor will discuss the efficacy of the drug in treating MG with a Medicare physician. Your doctor will have to have at least 2 articles that show the use to be effective for MG patients. Each article has to be from different sources. Our doctors typically use one from the AMA and one from the Neurology specific journal (there are several) which are published by separate entities. Sometimes it works and sometimes it doesn't. I don't know if it would work in your case or not. Good luck in your attempt to get it approved hun. I don't think that it will be an easy process though.. :-(

Rituximab (Rituxan) (L29472) - Medicare Policies and Guildelines
Original Determination Effective Date: 2009-03-02
Latest Revision Effective Date: 2014-02-13
---------------------------------------------------------------------------------------
Indications and Limitations of Coverage and/or Medical Necessity

Non-Hodgkins Lymphoma (NHL)

22 Previously untreated follicular, CD20-positive, B-cell NHL in combination with first line chemotherapy and, in patients achieving a complete or partial response to Rituxan in combination with chemotherapy, as single-agent maintenance therapy.]

22 Patients with relapsed or refractory, low-grade or follicular, CD20-positive, B-cell, NHL as a single agent.

22 Previously untreated diffuse large B-cell, CD20-positive, NHL in combination with CHOP or other anthracycline-based chemotherapy regimens.

22 Non-progressing (including stable disease), low-grade, CD20-positive, B-cell NHL, as a single agent after first-line treatment with CVP chemotherapy.

Rheumatoid Arthritis (RA)

22 In combination with methotrexate to reduce signs and symptoms and to slow the progression of structural damage in adult patients with moderately-to severely-active rheumatoid arthritis who have had an inadequate response to one or more TNF antagonist therapies.

Chronic Lymphocytic Leukemia (CLL)

In combination with fludarabine and cyclophosphamide (Fc), for the treatment of patients with previously untreated and previously treated CD20-positive CLL.

Wegener's Granulomatosis and Microscopic Polyangiitis

In combination with glucocorticoids, for the treatment of adult patients with Wegener's Granulomatosis (WG) and Microscopic Polyangiitis (MPA)

Medicare will consider the use of Rituximab as medically reasonable and necessary for the FDA approved uses as well as the following off-labeled indications:

22 Second-line or salvage therapy with or without radiation therapy (RT) prior to autologous stem cell rescue for progressive disease or for relapsed disease in patients initially treated with chemotherapy with or without RT in combination with bendamustine

22 Low grade or follicular CD20-positive, B-cell non-Hodgkin's lymphomas (re-induction treatment appropriate for responders and patients with stable disease)

22 Intermediate and high grade NHL when used as a single agent, in combination with a CHOP (Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone) chemotherapy regimen, or in combination with other agents active in the disease

22 Immune or idiopathic thrombocytopenia purpura

22 Evans' syndrome

22 Waldenstrom's Macroglobulinemia

22 For the treatment of refractory thrombotic thrombocytopenic purpura (TTP) for patients who do not respond to plasmapheresis.

22 Autoimmune hemolytic anemia

22 Rituximab is covered for those patients with autoimmune hemolytic anemia condition that is refractory to conventional treatment (e.g., corticosteroid treatment and splenectomy)

22 Steroid refractory chronic graft versus host disease

I know it's not the same thing but medicaid coves my rituxan. They are both government agencies you would think they would be the same

Hi Dee! Here's my personal experience with Medicare & Rituxan.
You are right. Rituxan for refractory MG is still considered by Medicare, as an off-label use. Not normally covered. That may change in the future, as small clinical trials are underway.
Even so:
My Neurologist and PCP filed paperwork with some sort of regional Medicare Panel - to get Rituxan approved for my refractory MG. This panel is actually part of a private insurer. (These days: I guess most of Medicare is actually administered by private companies).
As it was explained to me: the panel was presented with a summary of my medical history, including my myasthenic crisis, and the lack of response to Medicare approved treatments. The issue of liability was raised if the treatment was denied, citing studies at Yale, studies which showed excellent results against refractory MG.
Approval was speedily granted for treatment; I have been receiving Rituxan for 18-months. And it indeed saved my life.
(Sidenote to newbies: don't let this sort of thing scare you. Only about 20-percent of MGers ever go through a myasthenic crisis.)
There are other people here on DS, who are on Medicare and who are being treated with Rituxan. The general success of the drug - is becoming more widely known and appreciated.
1 of the key issues in all this, I guess - is the word "refractory" = not responding to any other established treatment.
Hope things work out okay - Ross
** Very important: IV-Therapies like Rituxan are generally covered under Medicare B. This covers only the first 80-percent of the cost (many thousands of dollars, for each infusion).
If you don't have it already, get a Medicare Supplemental Insurance, to your Medicare B. This will cover the other 20-percent , of any IV-Therapy (IVIG, Rituxan). I have one now, it costs $130 a month, paid quarterly at $390. I did not have this Medicare B Supplemental, for most of my treatment - and racked up a lot of personal medical debt.

Thank you to all. I will copy and print to take to my doctor's nurse. She could not get a clear answer when talking with Medicare. Maybe knowing what Ross and Angie has said.
I have Medicare and Tricare for Life (military) If Medicare pays then Tricare takes the rest. (actually, hospital ends up writing off a lot due to contractual with US Government)
I will keep you guys informed to progress.

Yes, he is talking about the peer review panel. Medicare no longer has their own dedicated insurer nationally. It is all resourced through private insurance companies now, such as United Healthcare, BCBS, Cigna, Aetna, etc.

Because you have two different federally insurance policies it means that if Medicare doesn't authorize it, neither will your Tricare. Tricare by itself is extremely difficult to work with (on many levels) but as you stated, if medicare pays then they will too. It's kind of an all or nothing deal with federally funded programs.

I hope that you can get this all authorized and you can get your treatment asap.
Hugs and love,
Angie

Thank you, Angie.
Peer Review Panel, I could not remember the name.