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AS, Humira, adalimumab-adaz, and troubles getting insurance approval
Hello,
I've recently been diagnosed with ankylosing spondylosis, and my doctor prescribed Humira on Dec 30th. I have CVS caremark for prescriptions, which requires the use of CVS Specialty pharmacy. I've now received countless emails regarding countless prescriptions, all ending in my request being denied because, they say, my doctors office did not response to a request for additional information. I called CVS specialty, and they told me the need a prior authorization form from the doctors office, which they have not received. They also said they have called the doctor's office and faxed the office requesting the prior authorization form many times, with no answer or response. Moreover, the doctor's office has now tried to prescribe the same medication 10 times (they prescribe it, and then cancel it when it doesn't get approved, which is the first step before requesting the prior authorization). I messaged this to the online portal, and the office manager told me that CVS Specialty has lied to me. That she has been doing everything. She listed the number of people she has spoken to on the phone. She even said that she has submitted a prior authorization. It's a very small doctor's office, and when I was there in the exam room it didn't seem like the most competent environment. In this case, it's hard for me to imagine that CVS specialty is lying to me about not receiving a prior authorization. Has anyone else experienced this? Do I change doctors?
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If you have a medical center or university med center with a specialty pharmacy in your area they may be able to give you advice on the approval process. The pharmacists and techs there handle these hoops much more often and effectively than a solo practice.
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1 ReactionI'm really impressed that you had the extra energy to write this comment after all you are going through with your pharmacy. Is this Medicare Part D? I recently commented on this subject on another thread. I have infusions of Simponi for RA because my rheumatologists have always said, it would be too difficult to get Medicare D to cover meds that I might take a pill or a shot at home. So I have had infusions every 8 weeks for 10 years. They have been covered under Medicare B because I go to an infusion center and RN's administer them.
Someone else mentioned that she was also on Medicare but her Medicare covered shots and pills. I think the difference would be what type of Medicare drug insurance you could afford. It will be different for everyone.
I'm sorry you are trying to find healing and instead getting stressed out by insurance coverage. The thing I've learned whe someone is lying or confused or angry with me, I make notes and date them and then I can back up what I believe is true. Wishing you some resolution with these things. Hope you check back and let us know how you're doing.
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1 ReactionHumaira has a Bio Similar (Generic) that my insurance has switched me to. They all cringe when I call it generic. First shot is today. Maybe others have experience with Bio Similar.
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1 ReactionI also had a bad experience dealing with CVS specialty pharmacy. The doctor's office said they submitted all the forms. But CVS specialty pharmacy claiming that the doctor's office did not respond.
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