ClaimCave

Prescription Claims

Medication coverage and pharmacy issues

Cigna is refusing to cover the biologic my rheumatologist prescribed for rheumatoid arthritis (Rinvoq, $6,800/month retail) and forcing "step therapy" through two drugs i already failed years ago under a different insurer. my employer plan is self-funded, so does Texas's step therapy override law even apply to me? and how do i document drug failures from an insurer that no longer exists in my records? also worried the copay accumulator is a second trap behind the first one.

diagnosed with rheumatoid arthritis in 2019, and i am now in week 11 of trying to get the medication my rheumatologist actually prescribed, while my hands get worse in real time. posting the whole...

Posted by confusedHomeowner197•
6 comments

BCBS denied my biologic for ulcerative colitis on the new plan even though i already failed step therapy on the old plan - specialty pharmacy is quoting $4,800/month out of pocket. how do i force the carrier to honor my prior step-therapy history instead of restarting the protocol?

switched insurance jan 1 from a UnitedHealthcare PPO (employer-sponsored) to a Blue Cross Blue Shield PPO (also employer-sponsored, but employer renegotiated carriers at renewal). same employer, same...

Posted by frustratedrenter499•
6 comments

Anthem Blue Cross denied my specialty medication prior authorization on a moderate-to-severe ulcerative colitis diagnosis after failed step therapy on three conventional agents (mesalamine, azathioprine, prednisone) over 14 months by citing a non-formulary status and failure to demonstrate medical necessity in a peer-to-peer review with a non-gastroenterologist reviewer. Forced approval and back-coverage of $48,200 in deferred treatment costs using the ERISA 503-1 administrative appeal framework, the specialty-matched peer review challenge, and the state external review framework. The five-element approach to specialty drug prior authorization denials on biologics and small molecules

Posting this because specialty drug prior authorization denials on biologics (Humira, Remicade, Stelara, Entyvio, Skyrizi) and small-molecule agents (Xeljanz, Rinvoq, Zeposia) for inflammatory bowel...

Posted by determineddriver340•
6 comments

Prescription costs $800/month even with insurance

My doctor prescribed a medication that costs $800/month AFTER insurance. Insurance says its a tier 4 specialty drug. The generic isnt available yet. Are there any options here? Manufacturer coupons?...

Posted by worriedDriver416•
5 comments

Prescription Claims lowball offer is insulting

Got the offer letter for my prescription claims claim today. They want to give me $1,800. The repair estimate is over $12,000.Are they serious? How do they expect anyone to accept this? I'm so...

Posted by homeowner_18•
6 comments