Navigating New Insurance and Biologic Coverage

Since getting a diagnosis of psoriatic arthritis, one of my biggest struggles has been dealing with health insurance. Learning about changes in coverage or hikes in copays is never fun. And once I aged out of being covered by my parents’ insurance, I had to navigate a totally new world of getting set up on new employer-sponsored insurance.

The thing I’ve found most difficult is changing insurances and getting coverage for my biologic.

In the past, I’ve switched insurances with relative ease. But last year I had a horrible experience when I got a new job. Not only was I without coverage for a short period (a total nightmare for anyone with a chronic illness), but getting coverage for my biologic, Humira, took several weeks. While waiting, I was in a flare between the stress and missing doses.

I learned many important lessons about preparing and advocating for myself during the process. If your insurance is changing soon, get prepared for change and get ready to potentially be on the phone for hours.

Join the free PsA community!

Connect with thousands of members and find support through daily live chats, curated resources, and one-to-one messaging.

Sign up

Prepare for transfer

I recommend refilling your current prescription early to make sure you don’t go without if there are any issues. Stocking up is especially important if you are changing jobs and have a coverage gap. But I think anyone facing a change in coverage should aim to have an extra dose or two on hand just in case there are delays or other issues in the approval process.

If you find yourself in a situation where you’ve run out of your medication, reach out to your rheumatologist and ask for help. Sometimes, they’ll have samples available that can tide you over. If not, at the very least, it helps that your doctor is aware of the situation so they know to stay on top of any approval paperwork.

Before your current coverage ends, you might also consider getting routine blood work done, as well as a tuberculosis (TB) test if you haven’t had one done within a year, as it might be required for prior authorization.

Understand your new coverage

Most major insurances cover biologic treatment, but it’s a good idea to review your coverage details to understand what you’ll be dealing with.

For example, some biologics might be easier to get coverage for than others. You might also be facing a new copay amount. Knowing these things beforehand means you can take necessary action, such as getting set up with copay assistance.

Get the ball rolling

Once you get your new insurance details and you’re officially covered, start making phone calls. It’s not uncommon for insurance companies to have their preferred specialty pharmacy that they require you to use, so be prepared for a pharmacy transfer.

I’ve found that the best place to start is to get on the phone with your current specialty pharmacy so you can give them your updated details and then go from there. They can sometimes point you in the right direction for your new pharmacy if it’s required, or your new pharmacy might even reach out to you directly. Best case scenario, you’ll stay with the same specialty pharmacy.

Personally, I’ve found this part to be easy — I was never left to figure it out myself.

Let your doctor know

Changing insurances often means getting new prior authorization. Prior authorization is a process health insurance companies use to determine whether they will cover expensive or specialized prescription medications and services. Biologics always require prior authorization.

The process involves the physician submitting a new prescription for the medication and the insurance company reviewing it to make sure you meet the criteria to qualify for coverage. There may also be an appeals process if you’re missing some of the requirements, such as needing a recent TB test or making sure you’ve tried other treatments that have not worked (also known as step therapy).

It can be so annoying to do this for a medication you’ve been taking for years, since getting prior authorization can eat up time. In order to keep the process moving, pharmacies often recommend giving your doctor a call to let them know you’ll need a new prior authorization soon.

If you require an appeal, it can be an even longer process: I learned that, usually, you will be denied for one item at a time.

So, first I was denied because I was required to get an up-to-date TB test. After getting the test and submitting the prior authorization again, I was denied again until my doctor could prove I had already tried other therapies. It was a very time-consuming process.

Be prepared to wait, fight, and keep checking back with whoever is on deck. My pro tip to help avoid a long battle is to ensure you get an up-to-date TB test.

Keep calling

Continue to follow up with your doctor, your pharmacy, and your insurance — whoever you’re waiting on. Online portals are helpful for keeping an eye on things, especially when you can see denials and approvals. But feel free to call if it’s been a few days with no news — sometimes, people need a nudge.

Reach out to your patient assistance program

While getting prior authorization sorted out, reach out to your patient copay assistance program. It’s the ideal time to get your account either updated or set up. These programs exist to help patients deal with the often high price of biologic copays by providing savings cards, reimbursement, and other methods.

I believe most name-brand biologics offer support services to patients. I’ve found these resources incredibly helpful. Sometimes, their support agents can help you through this process and provide multiple solutions for copay assistance that will work with your new insurance.

I was very pleased with my experience with Humira. The agents were able to help me prepare my copay assistance for my new insurance. It was all set up for when my prescription was ready!

A long but successful road

It felt like it would never end, but eventually my Humira was approved and covered. It took weeks and quite a few hours on the phone. I felt like such a pest, constantly getting on the phone with my insurance, doctor, and pharmacy, but it was necessary and worked out in the end.

I’ve since had to change my insurance again, and last time was much smoother overall: My doctor did not delay sending my prior authorization, it was approved without issue, and my new pharmacy was one I already had a relationship with, so there were no issues with transfer. I was so thankful.

It’s always annoying to switch insurance and deal with changing everything, but knowing what to expect ahead of time made things a lot easier the second time.