New Year, New Prior Authorizations

I honestly have a headache just typing the title for this article.

As anyone on any type of expensive medication knows, a new year means new prior authorizations are required – and as such, patient diligence, understanding, tenacity, and persistence must escalate, and quickly, in order to receive critical medications on time and without delay.

Being on biologics: my insurance recap

From 2018 through the fall of 2021, my husband's employer utilized the same insurance carrier - Aetna. So, my requests in January of 2019, 2020, and 2021 for the biologic I take, Remicade, were approved without much fanfare.

I knew to reach out to my infusion center as soon as the new year started, provide them a confirmation of my insurance information (or updated ID and group numbers if available), and request that they start the prior authorization process as soon as humanly possible. I’d also give them the date of my next upcoming infusion, and then typically call them to check on the status of the prior authorization communication about twice a week until it was approved or another problem arose. Honestly, for those 3 years, I was pretty lucky.

Changing insurance is such a pain with IBD

That changed when my husband switched to a new employer this past fall, and with it, we acquired a new insurance carrier - Cigna. While the November prior authorization process was painful and down to the wire on my infusion clock, it was made worse by learning that his new employer was changing insurance carriers to Anthem BCBS on January 1, meaning the approval I had finally secured would only last 2 infusions, and the battle would need to be replayed at the start of the year.

The nightmare of prior authorizations for biologics

In navigating this complicated, exhausting and all-consuming process multiple times over the last few months specifically, I want to share the challenges I experienced in case they resonate with you or make you feel less alone in your experiences.

Tips for navigating insurance coverage with IBD

Have an elevator speech ready

I didn't have one – a quick summary about why I was calling, and what I was asking – and so I'd explain the whole situation just to be transferred to another department or another person in the department, and I'd have to start all over again. This became infuriating and was a waste of my energy and breath.

Know medical vs. prescription coverage

My insurance provider covers my medical (health) insurance, but subcontracts to another company to manage my prescription benefits. This was a new experience to me and not something I'd dealt with before. I thought it was straightforward, until I learned that my infusion center had applied for prior authorization for my biologic from both companies, and they canceled each other out.

Before setting the paperwork in motion for a new year, determine which provider covers your specialty medication and who you need to connect with for prior authorization.

Be ready for frustrating paperwork

Paperwork takes time and gets lost in translation. For example, I was told the infusion center sent the request for authorization to the insurance on a Monday, but the insurance didn't have it entered into their system until the following Tuesday, meaning that more than a week of time was lost where my paperwork was "in transit," which is really frustrating for something that is transmitted electronically.

Keep a record of who you talk to

I found it critical every time I called for a status update to write down the name and direct extension of whomever I talked with, and to ask if they'd be calling me back with questions/additional information, or if I should reach back out to them.

IBD and insurance

If you've walked this walk this year (or in years past) with Crohn's or ulcerative colitis, what has been your experience? Have you come across other challenges that you'd warn others to prepare for?