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 They refused to fill it because they insisted the formulary changed on September 1st, my approval was no longer valid, and that I was now required to take the biosimilar.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}.
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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.
