Been awhile, not sure what to do when insurance apparently won't cover ANY biologic drugs?

Hi all,

I haven't been on this site in awhile, a lot has happened since I moved across the country for a teaching job. With a teaching job I figured my insurance would be way better and some stuff has been, lower copays on some medications, while others have been higher, like a colonoscopy costing 400 dollars.

I guess insurance has changed in 2015 (despite me calling back in December and the insurance woman telling me no major changes have been made) Now a lot of medications that I went to pick up with zero copays all of a sudden have copays ranging between 6 and 20 dollars. That all adds up every month! I have no idea what alternatives I could use.

But the icing on the cake was when I called to find out about the Cimzia (used to be, miraculously only 35 dollars, way better than what it was with my pre-teaching job back in NY). The woman said it wasn't covered at all. I could try to talk with my doctor and the insurance company about it being medically necessary but that doesn't usually get approved. She mentioned if I needed it that badly I could pay for it out of pocket, but if my memory served me correctly it was around 3000 dollar medication and being that that's around what I make in a month, yeah, don't think that's going to happen. And I already used the patient assistance card.

So, I decided let's check the alternatives. I used to be on Remicade before Cimzia. Didn't work as well. They told me that wasn't covered either. So I asked about Humira even though that didn't work back in 2010 and I wound up in the hospital. Yup, not covered.

So anyways, this is a lot of rambling, but I just don't see how it's possible for an insurance to now cover all three. It seems prejudice or something. Like I can't see insurance ever denying a diabetic their insulin shots, so how can they deny someone with crohn's or rheumatoid arthritis are medication? Some people need more than just pills alone. It's certainly not fun for me to inject myself every month, but it's what needs to be done. It makes me feel like I need to find a new job next year, even if that means quitting teaching, just so I can find an insurance that covers it. But that's still not going to help me Feb-June.

I don't really know what to do. I don't want to be all hopeless and self pity and woe is me but at the same time, unless the insurance people are complete morons and feeding me the wrong information, I feel like I'm at a complete loss here...

This does not sound right to me. You need to figure out how to dispute this....I believe you will win, but I'm sorry for the stress and the hassle. Here is some info that might help:

Webcast on Managing IBD costs and resources: http://www.ccfa.org/resources/webcasts.html#webcast4

Sample letter for your doc to send to dispute. (obviously you would put in your own info): http://www.ccfa.org/resources/certolizumab-pegol-booster.html

I live in AB, Canada, and they make sure that you cannot be denied biologics even if you can't afford any co-pay...it's through progress support, they will give you free meds if your GI RX's it to you and you cannot afford it, they even set you up with a Humira coordinator that takes care of everything pretty much for you. This if for Humira and Remicade, not sure what if any, other biologics are also looked after in the same way as I mentioned above.

Hi Sara - I don't know anything about you insurance, but I agree,look into it. I would also contact the drug company and look into patient assistance. When I was on Humira, and in grad school, The basic insurance I had didn't cover it. I qualified for patient assistance and received the Humira for free until I got married and got on a better insurance plan.