Stuck in the Middle Without Insurance Coverage

While my husband and I aren’t what many consider rich, we own a comfortable house in Michigan suburbia. We make enough money to afford some minor luxuries, like taking a road trip or weekend vacation once a year and spoiling ourselves with dinner out occasionally.

We’ve worked hard to put money away for a rainy day and needed it to weather some storms over the years. For the most part, we’re living our best life in the middle class.

So, why then can’t I afford my medication to keep my psoriatic arthritis and psoriasis in check?

Having two insurance policies

I’ve had the same health insurance through my employer for over 15 years. It is split between prescription coverage through one company and health insurance through another.

For healthy people without a chronic disease, our two—prescription insurance works pretty well. I never had a problem until a change in my plan about eight years ago, which meant injectable medications were no longer covered. That’s when my health insurance took the lead.

To receive my biologic, I needed to have my doctor give me my injection in his office. This was so that my medical insurance would kick in to cover the costs, but very few medications are approved this way because many are designed to be given at home by the patient with easy-to-use auto-injectors.

Luckily, my doctor prescribed a biologic that met my health insurance requirement and worked well to control my psoriasis and psoriatic arthritis.

Even with having two insurance plans, biologics are expensive, and the coinsurance was still more than I could easily afford. Thankfully, I applied for financial help through the manufacturer and was accepted with a $5 copay. Excellent!

Everything was going well for seven years, and then the medication stopped working as effectively. It was time for a switch.

Insurance denials for new biologic medication

During those past seven years, new medications came on the market. Based on my history of what biologics worked the best, it was time to try this new biologic.

Problem: it is only approved to be given at home with its auto-injector. Both prescription and medical insurance denied coverage.

Again, I turned to the manufacturer for help. After filling out paperwork and sending in the needed forms, the manufacturer informed me that I could get this medication for free based on our family’s income. This was the case for 18 months.

Frustrating insurance errors and financial eligibility issues

In January 2024, the pharmacy told me insurance covered my biologic. Really? Nope, I was told this is in error.

I spent weeks and weeks trying to get the correct information. The pharmacy blamed insurance. Insurance blamed the doctor. The doctor blamed the pharmacy. Everyone was pointing fingers, and I had no medication.

In April, I had been four weeks without my biologic, and my body was getting irritated. Honestly, I thought I would be much worse with the stress and lack of medication, but I still had stiffness in my back and fingers, and my scalp psoriasis was getting worse.

I finally got to talk to the right people at the manufacturer’s financial assistance line. We were able to straighten out the error from the pharmacy that kicked off this mess.

I was able to fill out new financial eligibility paperwork and get proof from my tax filing of income. I took it to my doctor to add the final pieces and fax in the paperwork.

Within five days, I was denied. Our annual income was $3,000 more than allowed under the program. In 2023 my husband received a raise that put us over the income requirement.

Based on insurance denial, I no longer qualified for the $5 per dose copay. The medication costs about $15,000 per dose. I need seven doses per year: $105,000.

That is simply unattainable for just about anyone in the middle class. In the past, getting the medication for free or for $5 per dose was a godsend, but I’m not asking for that. I’m just asking to not go bankrupt, keeping my psoriatic arthritis and psoriasis in control.

Getting by and other possibilities

Through my rheumatologist and my dermatologist, I have received enough sample medication to last for six months. That truly is amazing, and I am super grateful.

But the reality is I can’t keep getting samples over and over. At some point, they will run out, and I will no longer be able to keep my disease in check.

My rheumatologist and I are currently exploring other medications that will meet my insurance requirements, and we have six months to figure it out. Fingers crossed!