Humira Denial: Continuing Insurance Woes

I received a particularly nasty letter in the mail earlier this month from my insurance company that spelled particularly disastrous news. It stated that based on my current plan guidelines, my Humira would no longer be covered by them because they had not received any updated information on my tuberculosis status and testing—something which I had never heard of before receiving the denial letter.

It inspired quite a flurry of anxiety and distress because I need my Humira to feel better and keep going—and this is an experience I know that I'm not alone in, well, experiencing.

A confusing insurance denial

Now, because I got this on the weekend, I wasn't able to do too much with this new information, and with work and everything, I had to reprioritize and let this slip between the cracks. It turns out that was probably the best option because that same week, I received another letter from my insurance company detailing that my Humira had actually been approved based on my plan guidelines and that I should continue refilling my prescription as normal and as needed. What??

While this would certainly be good news (if true), it is still vastly confusing. At this point, I recognized I had to call my insurance company to find out what was going on. After waiting on hold for what seemed like an eternity, I was finally able to speak with a representative who informed me that I had received the previous letter about the denial in error, that my Humira had been approved, and that I didn't need to worry anymore about.

A big misunderstanding, luckily!

When $12,000 is potentially on the line (given insurance potential denial), not needing to worry anymore wasn't exactly actualized. I asked how something like this could have happened. Although she couldn't provide a complete answer, she pointed out a potential answer: it seems that my rheumatologist might have made a mistake in trying to get my Humira re-authorized. Instead of sending over a renewal of prior authorization, my rheumatologist had sent over a new prior authorization request, which was flagged by insurance because they were trying to find a new patient with my information who didn't have the necessary TB testing on file.

So, it seems that this was all a big misunderstanding that started with my rheumatologist. Thankfully, it seems that my rheumatologist had realized the mistake and sent in the correct paperwork since I received the approval letter from my insurance.

A small mistake resulted in a lot of worry

My reason for sharing this story is to showcase how something as simple as a small mistake from your doctor can really and powerfully impact your life. If my doctor hadn't caught his mistake and sent in the correct paperwork, I could have been left without my Humira for a while, which would have thrown my medication schedule off. This could have had disastrous consequences for my health and how I function.

Have any of your experienced a similar insurance situation? Let me know!

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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.

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