Been trying to start treatment for Crohn's (I have two strictures that need surgery if untreated) since September 10th. I know it hasn't even been that long compared to how long some of you waited. But I am still so frustrated.
Two weeks ago today, I thought, somehow, miraculously, United had approved Skyrizi, my first biologic, after initially denying Tremfya (and saying I needed to try and fail something else first, including Skyrizi) and then denying Skyrizi (and saying I needed to try and fail something else first, including Tremfya).
What I didn't understand was that they approved my maintenance doses of Skyrizi through their pharmacy/Optum division and *not* the loading doses through their medical division. My GI's office didn't notice that, either (?), or just took my uneducated word for it that it was approved and went ahead and sent me for some "pre-treatment" blood work to compare to after a few months of treatment. I rushed out to get that done on a Saturday then waited to see how to start.
That Wednesday, doc messaged all good to go, start Skyrizi. Okay... But how? I called the hospital pharmacy, they agreed it was good to go, they would mail it to me, etc. I was like, "But I thought I had to do three loading doses in the clinic before it's mailed to me?" They didn't know anything about that, it was a different department. So I messaged doc's office. They then realized the loading doses were still denied and yes, I'd have to wait on the maintenance doses being mailed to me. (Would they have noticed that if I didn't point it out...? Eventually, I suppose?) Also, United, hey, I can't even USE the approved maintenance doses without loading doses!! Or is that the "Gotcha, we'll pretend we'll pay, but we won't actually have to!" catch of it all?? (Most likely, just different departments and someone or some AI was merciful on the Optum side.)
Nurse claimed their "PA team" was putting in an expedited appeal that Wednesday (nine days ago). Meanwhile, I had applied to AbbVie's patient assistance program the week before and noticed they were still waiting on information from my doctor. Took a few more days, but we figured out AbbVie had the wrong fax number on file, I got the right one to them, doctor signed it this past Tuesday, said nurse.
Meanwhile, I thought, by law in my state, according to google and my experiences with a disabled family member in the past, an "expedited appeal" has to be answered (even if with another denial) within 72 hours, including weekends and holidays. So I called United customer service late Saturday. They had no record of an appeal. But it being UNITED, King of Rejections and Profit, I didn't necessarily think that was the truth and/or the customer service rep could have just been confused.
But I brought it up in message to the doc's nurse Monday. She said she didn't know about the expedited appeal 72-hour rule, that that was the PA team's department, but her computer shows the appeal is pending. Meanwhile, Tuesday, she said after the doc filled out the paperwork, they were giving it to the PA team, who would call me with questions and then send it to AbbVie.
I waited a couple of days again. AbbVie told me yesterday they did not have the doctor paperwork, but sometimes it can take 3 days to process. Still, between that and the United "expedited appeal" not being expedited, I just wanted to be sure the "PA team" was even starting these processes. I called (my first time calling in weeks--I'm trying not to be a "problem patient" because I dare to advocate) the office and the general GI admin staff lady, who definitely never dealt with me before to be annoyed with me, was very annoyed with me. But she did explain the "PA team" is not a "Physician's Assistant team" like I thought, but a third-party service off-site. -_- "Prior authorization team."
According to her computer, the appeal was pending and she had no answer about it being expedited or not or why an "expedited" request would take 8 days and counting, just kept telling me "it's a process." I get that! I just want to make sure everything on the GI's side has been done in that process! I'm fully willing to blame United if it's their fault, but if they really haven't even gotten the appeal... I just wanted to be sure! For the fin aid, she said the computer said it was sent Tuesday. I said, "Oh, good, thanks, I just wanted to be sure. AbbVie said they didn't get it, but that it may take 3 days." Her, sarcastically: "Well, it hasn't been 3 days, has it??" Me: "No, but I wanted to make sure it was sent in at all." "If they told you it was sent it, it was sent in." "They didn't tell me it was sent in! They said they were sending it to the PA team, who would call me with questions, and no one called me." She didn't really have an answer to that, but I got off the phone because I had clearly reached a wall.
Today, I called United again, and a new person again told me they have no record of an appeal. Are they right about that? Who knows! I called AbbVie again and they told me again they have no paperwork from the doctor and would try faxing it to them again. Are they still processing it? Who knows! I'm really wondering if this third-party "PA team" is the issue here and didn't follow through on either. Or maybe they did. I just think after waiting 9 days for an "expedited appeal" they did United claims they did not do and waiting four days for fin aid paperwork to be turned in they claimed they did and AbbVie claims they did not do, I can at least check if they really did either or it's a coincidence both these companies claim they didn't do it?
I tried to politely message the GI nurse again about it all, but I'm just... tired. I've had no treatment whatsoever this entire time (and I first sought help in July, not diagnosed until September). Just vibes and my own diet experimentation, no advice from anyone, even. I can manage and am managing, but I'm also running out of time to get the three loading doses in before the end of the year and me probably changing insurances yet again and fighting yet again.