Problems getting insurance to pay for Humira

If you have reached your max out of pocket you shouldn't have to pay anything for the rest of the year. Why do you think your insurance won't pay anymore? Could you explain a little more.

The definition of max out of pocket is the maximum that you have to pay for the year and then insurance covers everything. With my current insurance the year starts Jan 1, but in my previous job the year started Oct 1.

My employer insurance has a max of pocket of $3000. I hit that with my first infusion of the year. My co pay assistance covers all but $5. Insurance doesn't care who pays the max out of pocket -- me or co pay assistance.

yeah...i guess im not sure. I dont think my insurance covers the drug but im at my max out of pocket from all the labs and and stuff you have to go in for every month. Its a bit of a racket in my opinion. Thankfully i am fully in remission. The last colonoscopy the doc said he couldnt even tell that i had it at all. 100% fine. Yet im told i cant stop taking this for the rest of my life etc. I think my insurance only covers a very small percentage of the drug maybe....so max out of pocket doesnt count since they dont cover most of it in the first place.

I assume thats the issue.

Ill try and call in again tomorrow and see what they say. This is just BS. None of us asked for this. I have no family history of this or whatever "causes" it. Clearly nobody knows....yet to be a functioning member of society im made a complete slave no matter how hard i work. Good system we have. Yet the junkies and the folks that self inflict have all kinds of programs to "help" them out. I just dont get it.

Hopefully i can get this sorted out to a reasonable rate. Id be curious on what others have to pay.

Ill try sitting on the phone again today to see what they say.

I did ask the doctors about paying for this and they basically said they are there to diagnose and get the right drugs but they dont have anything to do with how much stuff costs, billing etc from the payment side....which i guess makes sense.

Either way im sure there is an answer here.

Well some good news....kind of.
I was on hold for 2 hours with the abbvie assistance number my pharmacy that fills my humira had on file. They had to call my insurance with me.

Anyway....sounds like my insurance only covers 80% of this drug despite being at my out of pocket max etc....and i need to pay~1950 per month. Not sure any of that math lines up as the humira is around 6k but whatever i guess.

For the remainder that i have to pay out of pocket i can submit for reimbursements at completereimbursement.com minus a small copay of $5 each month. Takes ~7-10 business days to get the reimbursement each month i guess. Oddly this money cant come from my HSA which makes no sense. Thats what it is for.

Odd that it all switched or whatever. Prior to this month i paid a $5 copay and that was that. The Humira would show up and thats how its been for years. My insurance hasnt changed or nothing. I just dont understand all of this new process etc....but whatever.

Has anyone used this completerebate.com process before?
They did say that i need a receipt from the pharmacy and also a picture of the humeria box and uplaod both to the site as proof.

I have Blue Cross Blue Shield.
Ill check with HR but I dont think they are going to care. HRs best interet is in favor to the company i work for and has nothing to with the insurance company and what they cover.

I do find this all a bit odd though. For the past 2 years or better none of this has been an issue.

That has been my experience too.......in the past. It was always a $5 copay and my HSA would pay that. But now they are saying the assistance has run out and to call the Abbvie Assistance...which i did...which lead me to BCBS saying even though im at my max out of pocket they dont cover any more than 80% of the drug and im on the hook for the rest....~2k per month. The assistance program said i have to pay out of pocket and then get reimbursed by using this website each month. Oddly when the reimbursements are approved or if they are.....you then get a paper check mailed to you which you tehn need to go cash. I am pretty sure you can link this to your bank account and have it done electronically but that part appears to be handled by yet another 3rd party and i dont like the sound of that. Its all quite the goat rodeo.

I suspect the pharmacy doesnt get directly reimbursed and they want you do pay so that they can potentially deny you and not the pharmacy. That way its your problem and you would be on the hook for whatever payment they say.

I remember back in the 1990s.....you got sick......you went in for whatever it was.....you showed them your insurance and it was done. Maybe $5 copay. Now Its all these crazy plans and HSA accounts and whatever other offerings....FSA etc. I have a HSA and i max it out every year figuring that would be my best option. Nope..still not fully covered. Ill have to call the pharmacy back and review this with them but im sure they dont care. They just want to get paid and give out the meds. They probably dont care where the money comes from.

i will call the pharmacy and confirm. Its just weird that it all changed. Nobody can really explain that either.

No this was AbbVie Patient Assistance i talked to.

It went like this.

Pharmacy called and said my previous assistance "ran out". They told me to call abbvie assitance.
I called abbvie assitance and they called my insurance co with me and talked to them to confirm my out of pocket max had been exhausted. BCBS said they only cover 80% of the med and im on the hook for 20%.

This is 2k per month.

The abbvie folks said i pay that out of pocket and then submit for reimbursement on the site each month with pictures and receipts etc and then they take 7-10 days to approve or deny and then they send me a check 3 days after that.

I think most of these co pay assistance have a max assistance each year of around $20,000. That's usually enough to cover the max out of pocket for most people and then after that insurance should cover everything. In your case, your company must have made changes to your insurance this year since you didn't have this problem in the past. Did they increase your deductible this year or how the prescription plan works?

With this disease and the very expensive meds we need good insurance coverage in the U.S. You are probably stuck for the rest of this year, but when open enrollment comes up at the end of the year, really check out your employer coverage and then talk with an insurance advocate. Depending on how much you make you could qualify to get subsidies for private insurance through healthcare.gov that would give you better coverage at an affordable price. Pay attention to deductibles, max out of pocket and especially the rules around drug coverage. I find insurance very confusing when comparing plans so it's best to work win an advocate. Each state has a pool of people who are independent and the consultations are free.

AbbVie (and others) have programs to help if you exceed the max the regular co pay programs cover. The extended assistance has different rules and works different ways. Some may have income conditions (if you make too much they don't help as much). Be sure to check all the rules so you don't get surprised. I hope they help for the rest of the year and you can get better insurance for next year.

Insurance is all so baffling. If you don't understand it, definitely get help.

My boyfriend, who also has UC, just got a weird automated message from his pharmacy saying he prior approval for Xeljanz has been denied. He's been taking it since 2020 and his insurance has not changed. He also got an automated message from his doctor telling him he needs to make an appointment. He wasn't able to reach anyone today because they were closed, but I thought of your post. I don't understand why they would say it was denied suddenly since he's been on it for over 3 years and he also still has 9 refills remaining, so I am wondering what's going on. It'd be nice if a real person called and explained when these things are happening to us instead of sending out a vague, stress-inducing automated message that gives no answers.

The assistants he spoke to were pretty clueless and not all that helpful. But his doctor is squeezing him in next week over his lunch hour so he will be able to figure out what is going on then. He isn't panicked like I would have been. Lol. I think it will be fine though. He hasn't actually seen his GI in 3.5 years...he hasn't flared since he was first diagnosed and they haven't made him come in, so he didn't. He got bloodwork from his GI done twice a year though.

The whole thing was weird...he just had labs done in April and this secretary lady was telling him he needs more labs done in June but wouldn't answer his question as to why. Nothing made sense. I kept recommending he try out the online patient portal to talk more directly to his GI like a lot of us here do. The insurance/med pre-approval denial thing no one was able to give him a straight answer to either. And his script says he still has 9 refills. So, I don't know if it had something to do with the fact he hasn't had an office visit in so long or what, but they never made that an issue before. I think I was more bothered by the whole thing than he was though, lol. Ive dealt with a lot more of this crap over the years than he has and my tolerance for it is pretty low. I'm sure it will be fine though. Thank you for asking.

I am going to send a message to my doc right now and check to see if he needs to see me in person. We've had phone appts but not in person for 2 years and insurance is requiring another PA in July -- apparently they are only doing them for 6 months at a time for some reason. My old insurance did them once a year.

Hope this all gets straightened out for him quickly. I would be freaking out. But I think I have PTSD when it comes to this disease so I take nothing in stride and don't ever like to rock the boat when things are going well.

CCinPA said...
I am going to send a message to my doc right now and check to see if he needs to see me in person. We've had phone appts but not in person for 2 years and insurance is requiring another PA in July -- apparently they are only doing them for 6 months at a time for some reason. My old insurance did them once a year.

Hope this all gets straightened out for him quickly. I would be freaking out. But I think I have PTSD when it comes to this disease so I take nothing in stride and don't ever like to rock the boat when things are going well.

Same here! I'd be freaking out and also mad. Interesting to note about the prior approvals. My current GI's office has been very good at renewing those automatically for me so far, but I did just get an insurance letter notifying me that mine expires in June, so I better double-check with my doctor just to be sure.

I think phone appointments should count just like any other. I've actually never met my current GI in person because he is 4 hours away (I know, I really should try to find someone closer again...it's not ideal), so I've only ever had telehealth appts with him. But never hurts to double-check.

Thank you!