Unfortunately, this is a really common and frustrating experience for people with lupus. A MyLupusTeam member shared that even after their rheumatologist sent labs and a full explanation for why a treatment was needed during a flare-up, their insurance denied it — twice. You are definitely not alone in this.
The good news is Show Full Answer
Unfortunately, this is a really common and frustrating experience for people with lupus. A MyLupusTeam member shared that even after their rheumatologist sent labs and a full explanation for why a treatment was needed during a flare-up, their insurance denied it — twice. You are definitely not alone in this.
The good news is that there are steps you can take to push back. Here are some practical ways to advocate for yourself:
- Call your insurance company directly — explain why the biologic is medically necessary. If the first person you speak to isn't helpful, hang up and call again. A different rep may have a better outcome.
- Ask your doctor to appeal — your rheumatologist can submit a letter of medical necessity or a formal appeal on your behalf.
- Check for manufacturer assistance programs — many biologic manufacturers offer copay assistance or patient assistance programs (PAPs) that can cover costs if insurance won't.
- Ask about preferred drug alternatives — check with your doctor if there's a comparable drug on your insurance plan's preferred list that could work just as well.
- Confirm coverage codes before appointments — ask your provider for the procedure and diagnosis codes, then call your insurer in advance to understand what's covered.
Don't give up after the first "no." Persistence really can make a difference, even if it takes time and energy you'd rather spend resting!
May 9
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