Thursday, October 23, 2025

Crohn's Chronicles :: When Insurance Fails

Back in August, I talked about my battles with the insurance over my Crohn's medication. When I received the letter that they were no longer going to cover it, that they were pushing me to the biosimilar, I was advised to contact my doctor as soon as possible to see if there was a less expensive medication to be prescribed. If my doctor wanted me to stay on my current medication, I could submit an appeal and fight.

I chose to fight.

In the 13 years I have been taking biologics and dealing with insurance companies, I am more than familiar with the game they play, the time it takes to walk through these processes. And because of the timeline I face to keep continuity in my treatment, I didn't waste any time in contacting my doctor and getting the ball rolling. I had already had the initial conversation with him about the biosimilars, because I was aware this letter was inevitably coming. So when it came, I was ready to respond. 

My doctor went through the appeal process, and miracle upon miracle, I received my approval! The medical director overturned the initial denial and authorized coverage for my medication through August of 2026. I was beyond thankful, and was relieved to move forward. I was able to fill my medication without any issues in September, and I thought I was set until next year.

In late September, I received a phone call from the pharmacy, informing me that I would not be able to fill my medication in October, but would instead be receiving the biosimilar. I figured it was an error, that they just didn't have the updated information, but asked how I could verify it. I was told I would have to wait until it was actually time to fill my prescription {in another couple of weeks}, in order to trigger the claim with the insurance. I thanked her, still thinking she was misinformed, but still called my insurance to verify they still had my approval in place. They told me they did, so I didn't worry about it.

Fast forward to October's refill, and of course, I was unable to get my medication. They refused to fill it because they insisted the formulary changed on September 1st, my approval was no longer valid, and that I was now required to take the biosimilar. I looped the insurance company in, which started a long and frustrating back-and-forth with wrong/misinformation, empty promises, lack of call backs, etc. 

One rep told me I needed 2 prior authorizations {wrong}.

The next rep hung up on me {rude}.

Another rep escalated it to the "back office" and promised I would receive a call back in 3 business days {I did not}.

When I followed back up, I finally received acknowledgement that I had a prior authorization in place and that I should not be having issues {thank you!} and that a supervisor would get it sorted with the pharmacy. I would receive a confirmation email the next day and would be able to fill my prescription then {lies}. This was when I first posed the question on whether I was facing issues because my prior authorization was dated the end of August, and the formulary changed September 1st, but reminded the rep that the whole reason my doctor went through the appeal process to begin with was because the September 1st change was coming.

When the supervisor emailed me back the next day, she informed me that things were not, in fact, sorted, that my prior authorization/approval was invalid, and that I would have to take the biosimilar. She cited the September 1st formulary change, essentially saying they were not going to honor my approval and I was out of luck. When I inquired further about my doctor's intent to address that September 1st change, she never responded back.

The final person I talked with got so far as to tell me she just needed to apply a code to get me my medication, but it was going to take up to 10 business days to take effect. I told her I didn't have 10 business days {I was due for my next dose}, and more importantly, I had been down this road before. What would happen if I got to the end of 10 business days and they came back with the same response as the supervisor from the day before? She did more digging and came back with the final answer and acknowledgement: they were absolutely NOT going to cover my medication, yes I was, in fact, being punished for being proactive, and I could file a complaint with the Virginia Bureau of Insurance in an attempt to compel them to honor my original approval. 

When I called the Virginia Bureau of Insurance to get more information about the process, I learned that it would take 30-45 days for a resolution, and that most of the information would be gathered from the insurance company. I didn't walk away from that conversation feeling confident they were truly going to be advocating for me. I haven't fully decided whether or not I am going to file a complaint; I may still. But I can't wait 6 weeks for a decision, only to be in the same place {and then also having skipped treatments in the meantime}. 

-------

This truly is a David and Goliath situation, and unfortunately Goliath wins here. My hands are tied. I have fought as hard as I can, within the bounds of my situation and reason. The right thing would be to allow patients who are in remission to continue on Stelara, until there is a change in their health status. Then move them onto the biosimilar. To move Crohn's patients who are starting treatment onto the biosimilar, not ones who are in the middle of current effective treatment. But the insurance company is not interested in what is right. They are interested in money alone. The insurance company gets to make decisions regarding my health, regardless of what my doctor says. It doesn't matter that I am in remission, it doesn't matter that my treatment is working, and that the science says that Crohn's patients shouldn't have disruption in their treatment. It doesn't matter that I have a history of issues with a change in formulary with a biologic. 

I have had my time to rant and rave and scream at all of the injustices over this. This is not the outcome I hoped for. I am super nervous about moving to the biosimilar. But the Lord is faithful, and I know that He will take care of me, whatever comes next. 



Monday, October 20, 2025

Erin and Laura Turn 40!

This past weekend, Laura came to Virginia, and we made a road trip to West Virginia for a little weekend getaway. We wanted a little girls' trip to celebrate turning 40! :)

We rented a cute little cabin in Canaan Valley, and the weather was gorgeous! We were lucky that the leaves had started changing colors, so the valley was awash in oranges and golds and reds. The tiny little ski towns were just that: tiny. So there was not much to see or do, but we walked around a bit to explore what we could, and we drove through Blackwater Falls State Park and Canaan Valley State Park. We ended up having to rent a Jeep because an AWD/4WD was required to access our cabin, so it was fun to do a little exploring in it.






We had dinner at the Canaan Valley Resort, and we showed up right at sunset with the deer grazing on the lawn! We returned the next day to walk around and explore some more, and just enjoy the beautiful day.





We hopped over the ski resort side, and took the ski lift to the top of the valley. We got to enjoy beautiful views of the whole area, and it was such a peaceful ride. We also got to enjoy some hot chocolate, apple cider, s'mores, and apple cider donuts at the end of the ride. It was the perfect fall activity!










Most of the time was spent chatting and catching up on life, resting, reading, and just enjoying the beautiful weather. It was such a sweet little getaway, and I am so thankful for Laura and her willingness to make the trek out this direction. Over 20 years of friendship, now spanning 2 states, and I am just so thankful. For all the life we have walked together, for the chance to enjoy a fall birthday adventure together, and for God's grace in our friendship.

The adorable sweatshirts Laura made for us!


Happy Birthday, sweet friend! Here's to our next decade! :)



Tuesday, September 30, 2025

{iPhone Rewind} :: September

Soaking up the gorgeous weather!

Sweet girl...school can be tough some days, but to know she doesn't hate it all the time...it makes the hard work worth it.

An afternoon drive for some ice cream

Maddie Girl has been a busy, artistic girl!

Flowers from Mike :)

We used some Coca-Cola for a science experiment and then I let the kids try some. They all said it was too spicy haha

Donuts with Daddy

The kids got to see some deer out on a walk

A Trader Joe's trip means a cute bundle of flowers from my love :)

Our fox friend has been hanging around, chilling in the yard

2025 Women's Retreat. So thankful for these women.



Sunday, August 31, 2025

{iPhone Rewind} :: August

We worked on a puzzle together over the course of a few days, and Eli was really focused on it!

We wrapped up our Summer of Fun! We didn't quite get to all the things on our list, but we still did a lot and had a great summer!

"Look, Mommy! I made a rocking chair for Norm!" Haha- I love this cute boy :)

We started reading The Wingfeather Saga and apparently there's a lot of suspense for Aiden haha

"Look, Mom! I can do a turban like Maddie!"

"You survived the first week back to school" flowers from Mike :)

We have been learning the books of the Bible {in order}, and the kids have done so great!

Aunt Vi sent some more beads to make bracelets, and the kids wasted no time making more!

Maddie wrote her first book! There are chapters and pictures, and she did such an amazing job. It was not a school assignment {she actually strongly dislikes writing haha}. She just decided one day she was going to write on her own and she sat down with her own creative mind and did it all herself. I'm so proud of her!

He has always made this face LOL

We found a fox hanging out in our backyard! He/she was there for quite awhile, and it was so fun to watch it.

Aiden lost another tooth! We were so glad when this one came out, because the adult tooth had already started coming in behind it!

Grandma crocheted Aiden a blanket for his birthday, and he has carried that thing with him everywhere. Anyone surprised by the colors he chose?

Just a few days after Aiden lost his top tooth, he lost another tooth, completely unexpectedly! He as eating a hard cookie and it just popped out. He was not a fan, but it saved us a little bit of the anxiety leading up to the loss, so I'm grateful it came out the way it did.

I love when Maddie and I get to go for haircuts :)

Maddie's drawings make me happy :)

I made an apple pie with the apples we picked at Stribling Orchard. It didn't turn out half bad!

We had a cookout with our community group, and Eli really loved playing this game with Mike

The kids loved painting rocks at Mrs. Celeste and Mr. Matt's house! (And it was a HUGE win that Aiden did so well with Ellie - their dog - so close to him)