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If You Weren’t Flaring Before…

I want to address the nightmare that is insurance claim denials. Of all the stressors that have led to a flare (beyond the physical ones), dealing with the bureaucratic nonsense of insurance coverage leads the way. Nothing related to dealing with RA has been more difficult, time-consuming, painful or flare-inducing than insurance issues.

The hassle of insurance claim denials

I was recently involved in a protracted fight over a medication that was denied. First, I need to give you a quick snapshot of the issue. I have been on a medication since March of 2014 that has successfully controlled my RA. It has been covered all of that time by the same insurance company. During that time, nothing about my medical profile has changed, nor has the medication. My rheumatologist had to submit a PA (prior authorization) annually, which is absurd in my opinion, but these were all successful. The medication is listed on my insurance company’s drug list 2019, for our plan, is shown as covered. 

My insurance would no longer cover the medication

So, you can imagine our surprise when I got a letter saying it would no longer be covered. No explanation as to why was offered. We were invited to send in any documents through an appeal process that might reverse this decision. My rheumatologist did that, including the 5 previous medications that I had been on that did not manage the RA, as well as clinical notes, etc. 

Another denial after the appeal process

I then got another letter, once again denying the coverage and again with no explanation as to why, what information might be missing, etc. This medication, if I were to pay for it, is approximately $2500/month. Clearly, not something we could afford. We are not eligible for the drug assistance program and yet, as a new retiree, I could not begin to cover an additional expense of $30,000 annually!

On the journey to getting some answers

So, my journey into the depths of insurance hell continued. I likely made over a dozen calls to various departments to try to obtain information about this. Finally, thanks to an advocate at my husband’s company (that is who insures us through his workplace), we got an answer. That last phone call took nearly 2 hours. 

The culprit: the delivery method of the medication

What was determined was that the delivery method for the covered medication was the source of the problem. They had decided to no longer cover the pre-filled syringe but would cover the Clickject version. So when my doctor put in the prescription for the same medication, delivered the same way it had been for 4 years, it was rejected. Despite the fact that auto-inject is more expensive, this is what they WOULD cover. Why this was not shared with me or my doctor remains a mystery.

Trying to figure out why this happened

My rheumatologist has his own theory and I think he may well be correct. He believes that by denying coverage for even one month per patient this represents over a billion dollars that is not paid out and increases the profits for the insurance companies. After this, I believe it as well.  We are still not certain this will resolve the issue, but I am hopeful. Now the clock starts again, with my doctor having to re-submit all of the documentation but this time for the Clickject version of the medication. Fingers crossed this works.

Stories like mine are all too common

What is so disturbing is that my story is not only common, but typical, for patients who are simply trying to manage their disease. I have not met a single RA sufferer who has not had at least one instance of insurance hell. I tried to tell the insurance company that by denying patients medications that have or could control our RA, you are likely sentencing us to a life of joint erosions, joint replacements, extreme pain, disability, etc. Not to mention the mental health decline. All of this means a much higher cost to them in the long run. Yet, someone sits at a desk, looking at algorithms, and randomly decides not to cover our claims, often with no legitimate or logical rationale.

Of all that we deal with when it comes to the management of RA, I believe wholeheartedly, that insurance issues are the single biggest cause of disease flaring. Either because a claim is denied, robbing us of the necessary medical treatments we need, or because the emotional toll it takes and the stress it brings causes our immune systems to rebel, aggravating our RA.

My wish for all of us is a system that is both fair, practical, and has the patient’s best interests as the primary consideration.

Nan

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The RheumatoidArthritis.net team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

Comments

  • tulugaq
    1 month ago

    While I have had no problem with RA meds, I also need a ridiculously expensive asthma inhaler. For years that has been covered by insurance. For much of that time, my doc had been fruitlessly prescribing the generic version. For some reason, when we moved to a different state and changed insurance carriers (same company, different state), his script for the generic was filled — but then DENIED by the insurance company. The original, full-price version was still ok….

    And it’s not only insurance companies that make us crazy (and hurt). When we moved, I asked my (well-researched and highly rated) new rheumatologist to fill out the forms for a new handicap placard for the new state. After months of nagging, she finally sent the paper work to me — for a TEMPORARY placard (I have had and used a permanent placard for 10 years). When I asked her why, she said permanent placards are for patients who are bedridden. I called her immediately on this blatant lie — to no avail.

    I now have a new rheumatologist — and I’m still using my old placard (no one seems to look at them anyway).

  • Dalia
    1 month ago

    Yuck! Hate this – the dang insurance company shouldn’t have a say in what we need as recommended by our docs. I’m appealing a procedure for my spine that they “think” may take up to 3 months to resolve. Get so mad you just want to shake them! Keep fighting!

  • Daniel Malito moderator
    1 month ago

    @nmhart14 I had to take the fight all the way to an administrative law judge one time. It took an entire year where I had to suffer on a lesser med in the meantime, but I won the case easily. The judge was the first real human being I talked to – they purposely didn’t let me speak to any of the appeals people at the insurance company because they know if you happen to inspire even a tiny bit of human emotion, you’ll be approved. So we fight, what else can we do, and we add more stress to an already stressful situation. At least it keeps us busy I guess… Keep on keepin’ on, DPM

  • Lawrence 'rick' Phillips moderator
    2 months ago

    Oh Nan, I am so with you. I am fighting with my insurance company over insulin. Thankfully insulin is still covered, but this is about the method of paying for the insulin. Same insulin, a big difference in the cost to the insurance plan.

    The former way is less costly to who? oh yes the plan and me. The new method of delivery, more costly to the insurance plan by over double and me. Darn, it makes sense, it was operating so well until January. Yes, I will likely lose the fight, but this fight is well worth the trouble.

    So another month, another argument. This one has been raging for 9 months now. It has been in appeal for 8 of those 9 months. I am still waiting for a decision. Yes we might call that a low priority problem, but when has saving money ever really been an insurance companies priority.

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