We all face health issues from time to time, and with that comes layers of complex problems to solve. I recently started Humira, and I had no idea how incredibly hard, and how long the process would be. Getting it approved was one thing, but waiting to actually start administering my injections was an excruciating mental battle of emotions. My health dangled in the wind while my fate was being decided by individuals who said "don't worry, everything will be ok." Little did I know, everything was far from okay. That got me thinking. Of course I'm not alone in this battle. I started doing my research, and was astounded at the millions of people and stories out there from those facing enormous health challenges.
My hope is that someday we adapt a Universal Healthcare system similar to Canada, and our European friends. Until that day comes, it's so critical to educate yourself as much as possible, and take control of your own health. Being your own advocate brings a sense of empowerment as well as knowing you've done everything you can to ensure you get the best health care possible.
As I sat in my gastroenterologist's office, we discussed the plan to start Humira. It's a specialty medicine, so the cost without insurance is a whopping $7,389 (approximately)....for a one month supply. That's two injections per month x 12. You do the math. Wowsas, that's a lot of moola! No wonder insurance companies don't always cover the cost. I am very fortunate our insurance does cover my medication, but not everyone has that luxury. To be denied coverage for a medication you need to live seems absolutely criminal to me. Have you ever heard of Step Therapy/Fail First? Some insurers require people to try other medications (less expensive ones) first, and fail on those medications before granting access to the originally provider prescribed medication. Ludacris, right?
I was told by one of the GI nurses that everything would be handled. In a nutshell, she was going to be the one communicating with the PA (prior authorization) team, and my insurance company. I offered to do all of the legwork, but she assured me that wasn't necessary. This is probably a good time to mention that the sooner I get started on Humira, the sooner I can start the taper OFF prednisone, so time is of the essence. I left the office feeling good with the plan, but I'm a take charge kind of gal, so I made sure to do daily check-ins to see the status of my medication. I knew it would take a few days, but after a week I started growing concerned. Regardless, the nurses assured me the process was pending and I just had to be patient. I just had a gut feeling something was wrong. Pun intended. On the 11th day, I checked in, and I received a long e-mail back stating how sorry they were, and that someone had dropped the ball. Basically, they submitted my paperwork via e-mail. There was no hard copy sent nor a phone call to made to make sure the electronic form came through. To say I was upset is an understatement. I was fired up, pumped up with prednisone, and ready to be my my own advocate. Safe to say, the fire beneath me had been lit.
From that point on, I took control. I demanded the name and number to the PA department. I spoke to the person who had been in charge of my case, and rather then express my extreme disappointment, I remained calm and cool. I didn't want to end up in a worse situation by not being able to keep it together. I requested a copy of my PA form. She was very nervous, and fired back a million questions (i.e. what will you do with this form? Are you going to send it to the insurance company?). She further went on to tell me NOT to send it to my insurance company because that would throw a wrench in the process. What did I do? You bet your a** I obtained my PA form, and sent it via fax, e-mail and hard copy - BAM! My husband and I tag teamed. While I handled the paperwork side of things, he called and followed up with our insurance company. Guess what? We were able to get Humira approved by insurance in less than two hours when we were originally told the process could take up to 2 weeks.
My goal in sharing my story, is to let you know you're not alone in your battle. I see YOU. I hear YOU. Take the reins, and take a stand. You deserve the best care available to you, and need access to it in a timely manner. Your health and life depend on it. Below, I've listed a few tips, and pointers I've learned along the way.
Request a copy of your PA (Prior Authorization) form. Despite what the person says on the other end of the horn, it's your right to obtain this. It's also good to have for your personal medical files as well.
Send your form via fax, e-mail and hard copy. Cover all of your bases. Call me old school, but I like to actually speak with someone. There is so much communication that is misconstrued through e-mails, texts, etc.
Have your insurance company on speed dial. Don't worry about being annoying. The squeaky mouse gets the cheese, right? Make sure to call and follow up to check that someone received your form.
IMPORTANT NOTE: Have your provider mark your form as URGENT. This will expedite the process.
As always, trust your gut. If you feel something is off, it probably is
To learn more about Step Therapy/Fail First, and ways in which you can be a patient advocate, the Crohn's and Colitis Foundation is an excellent resource. Contact your local legislators today, and get involved. CLICK HERE for more information.
An educated patient is an empowered patient
Action expresses priorities - Mahatma Gandhi