Insurance

Really I’m just here to vent to a community that will understand. I’ve been on Humira for almost exactly a year. I previously failed on NSAIDS, and was taken off Methotrexate after about two years due to elevated liver enzymes. When I was discussing biologics with my MD, I made sure to check what was covered/preferred on my insurance. Humira is Tier 2 (no biologic is Tier 1) but still required prior authorization. Now, I am a pharmacist so I know exactly what all that means and how it works. The PA was approved and I started therapy last April. Almost immediately felt better, although it did take a full 6 months to see the full benefit. I’ve had less pain, joint swelling, and fatigue than I’ve had in YEARS. I did miss a dose (my fault, I misfired the pen) in December and it set me back a bit (had to go back on steroids, yuck) but overall I’ve had a lot of improvement. Since it’s been a year, the prior auth expired and needs to be re-approved. Well I came home last night to a letter from my insurance saying they had DENIED the PA. I am FURIOUS! Per the letter, they didn’t feel that my MD indicated that I had improvement in symptoms. Are you freaking kidding me?!? I feel the best I’ve felt in years and that’s not improvement?!? Being a pharmacist, I’m pretty jaded about insurance companies but this is just maddening. Of course, the decision is being appealed by my MD (the specialty pharmacy I use is pretty great, they are facilitating). I also called and gave them an earful last night and they are going to re-review the decision as well. Overall I feel like I have a pretty mild case of PsA but I’d certainly like to keep it that way! Grrrrrr. Thanks for listening.
Submit your own question!