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Has anyone, when starting a new biologic been given the first month doses then receive a letter saying this drug is not on our formulary?

A myRAteam Member asked a question 💭
Utah

I've messaged my doctor telling him that I'm not starting a drug for a month then to have to change meds. He said his team has already started working on the exception process. He said if they don't process a pharmacy drug, he will try it in the medical side. Then I would have the med at the infusion center.

February 12
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Answer Summary

Members shared widespread frustration over insurance companies denying or changing coverage for biologic medications after treatment has... Read more

Members shared widespread frustration over insurance companies denying or changing coverage for biologic medications after treatment has already begun, often requiring prior authorizations, appeals, and formulary exceptions that can take weeks to resolve. Several members offered practical strategies including always getting pre-approval in writing, working closely with doctors to appeal denials or switch to infusion-based administration (which may be covered differently under Medicare), and applying for pharmaceutical company copay assistance programs that can reduce costs significantly. A recurring theme was the exhausting reality of fighting insurance barriers year after year, with members encouraging each other to advocate firmly, stay persistent through the approval process, and prepare for coverage changes especially when transitioning to Medicare at age 65.

myRAteam

Has anyone experienced insurance formulary issues after starting a biologic?

It's frustrating to start a medication only to face insurance coverage issues. Your situation isn't uncommon, and it's good that your doctor is already working on solutions.

Your doctor's approach makes sense - pursuing an exception process Show Full Answer

Has anyone experienced insurance formulary issues after starting a biologic?

It's frustrating to start a medication only to face insurance coverage issues. Your situation isn't uncommon, and it's good that your doctor is already working on solutions.

Your doctor's approach makes sense - pursuing an exception process first, then potentially switching to infusion center administration if the pharmacy route doesn't work. This is actually a common workaround when insurance coverage becomes an issue.

Why the infusion center option matters:

Some biologics can be administered either by self-injection at home or by infusion at a medical facility. When insurance won't cover the injectable version through their pharmacy benefit, doctors can sometimes get approval through the medical benefit instead, which would mean receiving the medication at an infusion center.

Infusions typically take anywhere from 30 minutes to a few hours, depending on the specific biologic. While it requires going to a facility, many myRAteam members have found infusions work well for them once they adjust to the schedule.

What you can do:

Stay in close contact with your doctor's office about the exception process. They're experienced in navigating these insurance challenges and advocating for their patients to get the medications they need.

February 12
A myRAteam Member

So frustrating. I'm so sorry this happened. I've had this happen but not a month after I've started. Ugh. Hopefully the doctor working with you through the process can get you approved for the higher tier. It's maddening how much power the insurance companies have.

February 12
A myRAteam Member

My doctor's office starts on things right away. I just got the call from the insurance that they approved the exception.

February 13
A myRAteam Member

Sadly this situation is pretty common with specialty meds. Sometimes the first fill goes through under a temporary approval, and then the insurance reviews the formulary and pushes back.

Your doctor’s office handling an exception or moving it to infusion billing is usually the next step and often works. Many people end up staying on the same biologic after the paperwork battle; it just takes time.

February 13
A myRAteam Member

Same, but different... My dr. knew we would need to make a change when I turned 65. Under Medicare, injections are covered as a drug. Infusions are considered a procedure. I took a break in treatment because I was doing well and didn't want to do infusions. Waited too long, Then, it took several failures to find the right one. Before I got the inflammation back under control, I had a lot more joint damage. I've been doing infusions now for a long time (maybe 7 years?). I've had a few hiccups along the way, but for me, they work better with no real side effects, and I don't need an additional Rx with it. This comes from someone who is not an easy stick. The biologic I'm on is given every 8 weeks. Carol, I know you stay on top of your treatments, but maybe someone will learn from my mistakes.

February 12

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