Does anyone have trouble getting Humira approved?

My insurance which is a Medicare part c plan, put me on “bio equivalent “ Humira this year and I’ve been fine. As far as I know there are two “bio equivalents”. Three years ago my doctor and I got Humira direct from AbbVie Assist Program.

Why is her doctor not handling the appeal? My doctor has always handled my drug appeals with a letter of medical necessity, provides my medical records and participates in a peer-to-peer-review with the insurance company. She lays out why I need a specific drug, that I have already been successfully treated on a drug, that other drugs have not worked, that it would be detrimental to my treatment to switch etc. I don’t understand why the pharmacist is handling this for her. My son has epilepsy - same thing: his neurologist handles his drug appeals when he needs prior authorization or when something is denied. It doesn’t make any sense that they do this every year to her and you’re right - each time she is off it, there is no guarantee when she goes back on that it will work. I hope she can get it approved and figure out a way to get it every year with no lapse.

Unfortunately, Blue Cross is awful everywhere in regards to denials; here;s what you can do: ask,for an external review ; the ins. Company pays for,this—not the patient or family. I was prescribed Humira, but in’s. Company denied and said I must try a biologic first. I am on Flyoma which is what they decided and it works so far for,the recurrent uveitis and about 85% for,GI /joint issues. Healthcare in the US is expensive and stressful.
best wishes getting the Humira!

@jsbart1
Thanks for your response and I'm glad a new equivalent is working for you. They want to switch her altogether to a - targeted synthetic DMARD, Rinvoq. She has tried other bio equivalents but can't remember the names.

@pm56
Hi, her clinic has an onsite pharmacist that handles all the appeals and works on getting all the back up documents needed. They are now working on the second appeal and then will need to go to external review. The process takes soo long with each appeal that there is potential for her to run out of doses which is what she is coming up against right now. It's possible AbbVie will help fill in those gaps while she waits. Thank you for all your information! It's just so frustrating & seems that they just don't look at it at the human level of people just trying to live their lives, take care of kids, go to work, etc., all to save a little bit (when she last checked, RinVoq and Humira are close in price) Anyway, thank you again!!

@janeinnc
Thanks for much for sharing, yes it was a little easier and faster when this would happen with Healthpartners. Yes, it is so expensive and stressful for sure. Take care!

@lisanoelg1 For what it's worth - Rinvoq is supposed to be an excellent DMARD as well. I've been on both (it's just unfortunate I developed a DVT within a week of starting Rinvoq - but it's also close to the time I'd had Covid, so it was difficult to tell which was the cause, but because of the timing, I was advised to discontinue to the Rinvoq). Either way, hope she gets what she needs with less hassle. Or . . . just a thought, does she have the option to change her insurance? They're all painful to deal with, but maybe the pharmacist can point her to one that is better to deal with when it comes to getting drugs approved.

@lisanoelg1 Indeed i did...found a new dr. got on orencia and am doing great on that...i chose infusions this time but orencia is also available in shots you inject...good luck

@pm56

Thanks for that helpful information. She may look into a different insurance option at open enrollment for 2027. Thanks, I'll pass along your well wishes!

@ruralgal76
Thank you, I'll mention the Orencia to her-