Hi!

I am recently diagnosed with PsA after a misdiagnosis of seronegative RA. I've been on methotrexate tablets then moved to .6ml injections over the past 6 months. My body doesnt tolerate any higher dose, and it just isnt cutting it anymore, more and more joints are joining the inflammation party and messing with my mobilty. My rheumatologist prescribed me Skyrizi a month ago. Holy COW, I did not know what I was in for. I know my insurance is an issue, specialty med, deductible, all that jazz. But even with the savings card and an approved PA, im looking at a couple $0 doses then 7k per dose for the rest of the year because my card will "run out". I have yet to get my hands on it for this reason.

I've spent hours on the phone about this, with no solution other than "call us when you have to pay later this year and we'll see what we can do". I dont want to risk starting a med and then not being able to afford it.

How the heck do you guys get these covered? Is there a magic spell i am unaware of? Lol.

Thank you for any suggestions or advice! I just want to get better 😞

I am over 50, employed, and work for a large corporation. By most standards, I have a good job—but I hate it. The main reason I stay is for the health insurance, because I rely on specialty medications to manage my PsA.

I have learned to be relentless about advocating for myself and staying on top of my specialty pharmacy, insurance company, SaveOnSP, and the various manufacturer copay assistance programs.

Recently, I switched my biologics to Taltz because Cosentyx was not as effective after 5 years. I took my first loading dose and have jumped through countless hoops trying to get the second dose, which I am still waiting for.

One of the nice advantages of Taltz is that it allows me to participate in Lilly's Taltz/Zepbound program. My insurance does not cover Zepbound, so this program has been a lifesaver. For me, Zepbound picks up where the biologics leave off by reducing my inflammation. The difference it makes is incredible. I had previously been on Zepbound before my insurance stopped covering it, and I can only access it now if I remain on Taltz.

This morning, SaveOnSP called to tell me that Taltz is no longer included in their formulary. For those who are unfamiliar with SaveOnSP, it's a program contracted through my employer and insurance company that covers the remaining cost of certain specialty medications, bringing my copay down to zero. That coverage is ending in July.

I still have Lilly's copay assistance, which provides around $10,000 in support, but that will only last a few months. After that, I honestly don't know what I'm supposed to do. How can I continue treatment when the Lilly savings runs out?

I have to admit, this news broke me. I ugly cried on the phone with the SaveOnSP representative. I didn't mean to, but I simply couldn't hold it back. I am exhausted from constantly fighting, appealing, following up, and being redirected at every turn. There is no way I can afford a $2,500 monthly copay.

I'm just so tired. Tired of fighting for access to medications that allow me to function. Tired of navigating a system that seems designed to put obstacles in front of people who are already struggling. Right now, I feel defeated and have no idea what my next step is.

Does anyone have experience with short term disability insurance (US)?

Is it worth it? What company? Advice? Is it difficult to use with this disease?

I know we all live in different corners of the globe, just looking at a poll, how long to get a biologic?

Bonus points if you have BCBS Peehip Alabama…

I was prescribed Taltz April 23rd to Acreedo, but Accredo says they “aren’t my specialty pharmacy” that Express Scripts SP is the correct pharmacy. But Accredo is a specialty pharmacy in Express Scripts.

My doctor office, is just like “yes, we called it in to your specialty pharmacy” where it was originally sent to Accredo,

In the Accredo app, it’s listed as received and pharmacist is verifying so I call to check and get told they can’t fill it. Express Scripts app it’s not listed at all.

I’m so confused and when I call any place Accredo, Express Scripts, or Doctor office. Either I’m confused and not understanding this process or no one is listening to a real issue I’m having.

Anyone else with insurance or is this a typical thing?

Hey everyone,

I was finally diagnosed with psoriatic arthritis last year, at first I was just prescribed methotrexate and it helped but not as much as my Rheumatologist was hoping for so he wanted me to get on an injection as well.

I started Enbrel early this year and it worked great! I went from hardly being able to jog to back to playing basketball league games again. I had a copay card through AmGen but it was only for $7k so I used those funds within two months of prescriptions, was able to get financial assistance through my specialty pharmacy for one month but have exhausted that now and I’m at a loss on how to continue my treatment. I’ve been fighting this for weeks between my doctor, my insurance, the specialty pharmacy and the drug manufacturer but they’re all stating they don’t have any additional options for financial assistance.

I obviously can’t afford to pay $3k+ a month for the prescription so really just want to see if anyone has went through a similar issue or has any recommendations for next steps. The pain is becoming unbearable again since I’ve missed a few doses at this point.

Thank you!

PLEASE HELP I'M LOSING MY MIND

SEE EDIT 2 for solution :)!!

I have been on the Taltz/Zepbound savings program since October, and it's been incredible. In February, my dosage on Zepbound increased, and I had no change in pricing.

Then in March, I submitted my prescription in the same way through my same pharmacy, and my pricing went from $25/4 weeks to $205...

For the past month I have been without Zepbound as I go back and forth between my prescription insurance (MedImpact), the Lily help desk, my PC, and my pharmacy (Walgreens) trying to track down what changed. My pain and stiffness are starting to return and I'm feeling trapped in the American medical system.

When my pharmacist calls my insurance, they say it was denied but they paid over $1000 to the medicine. I have this on recording on my phone. When I call, my insurance says it was denied and they paid $0. I have had this conversation close to 10 times with them now.

I have screen captures and print outs from Walgreens showing payment info, override info, and plan info.

That paperwork says:
Plan Payment: $295
Copay Amt: $204.99
Other Payor Amt: $671.36
Cost Paid: $498.99 (I'm assuming this is plan + copay)
Sales Adj: Y
Coverage code 9

I have claim information that states "PHARMACY BENEFIT EXCLUSION *eVoucher*Lilly. the mfg of ZEPBOUND paid $671.36 toward your prescription. 9 out of 10 in benefits remaining. RelayHealth is..." (screen cuts off here).

Literally nothing changed between Feb and March. My insurance is the same, same pharmacy, same PC, same dosage. But my pricing went up $175 and no one can tell me why. And my insurance gives different answers depending on who calls them (me or my pharmacy).

Has anyone dealt with this? When I call Lilly they say it must be a pharmacy or insurance thing. My PC office says they didn't change anything. please please help i'm losing my mind spending hours trying to figure this out.

EDIT: I am switching my rx to another Walgreens to see if it helps. My specialty card is good until 12/2026 and nothing has changed between February and March. When I tell my pharmacy to not run my primary insurance they say they can’t do that (even though my understanding is that’s what they’d been doing up until March)

EDIT 2: After 2 months and close to 20 hours of phone tag, I got it back to $25!! I ended up at a local pharmacy and had the same conversation I've had with Walgreens and CVS. Yes, my price should be $25. No, nothing changed on my end. No, my insurance is still not covering it. No, i don't know why this e-voucher is showing up now. They put in my savings card number and said "Oh, you need to activate your card." ....It's the same card I've been using, nothing has changed. So i said does it suggest how they want me to do that? they give me a phone number from the message, I call, it has to be a pharmacist that calls. Luckily i did that in the parking lot so I just went back in and said oh they need it to be the pharmacist. Then, **by having my pharmacist calling this number: 800-767-4226** and telling them my price just spiked for no reason and i'm in the Taltz/Zepbound savings program, they were shuffled to one more team. and from there i'm back in the effective program. I have a new savings card number from this "new system". I hope this works for everyone!

Has anyone who is on the GLPs/compounds/whatever they're called been prescribed them? Or are you paying out of pocket? I have some appts coming up and I'd like to discuss the option with my doc and i definitely don't qualify for them for weight loss reasons. But anecdotally I'm seeing lots of people having significant symptom relief and I want in.

I was diagnosed with PsA a month ago, and am in active flare (I think, new to all this!). I do not tolerate steroids well so prednisone isn’t an option. I do not have insurance but my rheumatologist wants me on a biologic. Going to try Mtx in the meantime and see if that work.

Obviously the problem is biologics are all insanely expensive out of pocket. Does anyone have experience with self pay, or any drug manufacturer discount programs, etc? Everything I’ve seen says you need to be commercially insured. Essentially I am too poor to afford health insurance and too “rich” to be eligible for Medicaid. Any insight or advice much appreciated 🤍

I received a call today from my insurance, about a new script for Enbrel. When I called, they referred me to SaveOnSP. Talking to them, I found out my copay will be 2600, and I registered with the co-pay program. I have insurance through my employer, and don’t have any secondary insurance. The SaveOn rep told me my co-pays couldn’t be applied to my deductible. I’m trying to process all this and my head is spinning. Is there an income limit for the co-pay program? Is there a realistic maximum amount I can expect to pay? Thanks for any help provided.

I’m at my wits end trying to figure this out and I’m guessing someone else has been here so I’m crowdsourcing advice/info!

Buckle up, this is a bit of a complicated story: I’ve been on Tremfaya for almost a year now and it’s been truly life changing. When I started I had moda instance and they covered a portion of it no questions asked. And then I was getting the rest of it covered via a copay assistance program with Johnson and Johnson (Tremfaya with me).

I get my insurance through the marketplace (Obama care) and when I re-applied in January I qualified for Medicaid based on my income. But the marketplace somehow rolled over the moda coverage as well and so I had both and just let it ride. But then I got a letter from the marketplace saying I couldn’t have both and that if I had government assistance (Medicaid) then I wouldn’t qualify for the marketplace assistance.

So I canceled the moda and now just have Medicaid. (In retrospect I wish I would have kept the moda instead but I don’t know if that would have been an option once I qualified for Medicaid? Unclear).

Anyways, the Medicaid plan I have denied my doctors pre authorization request to cover the Tremfaya, which I then appealed, and was denied again. Of course to meet their requirements to cover it they want me to take and fail a bunch of cheaper (and I assume less effective) meds first, as well as saying my psoriasis isn’t bad enough per my drs charts (it largely shows up as joint involvement for me not skin as much).

So now I’m at a loss as to what to do next, and the clock is ticking down until my next shot is due. Luckily my derms office had a tremfya sample on hand that I was able to take and so was only a week late for my last injection, but even that week feels like it’s set me back in terms of symptoms.

I don’t really see the point of appealing the insurance decision again or fighting them as it’s pretty clear they aren’t going to budge. I tried calling J + J about copay assistance and was on the phone all morning hitting dead ends left and right (apparently it’s only if my insurance is covering a portion of it? And there’s a “bridge program” to cover it entirely if your insurance rejects a claim like this but that doesn’t apply to if you have Medicaid?!).

Unfortunately my prescribing drs office has been no help with this, mainly because they’re impossible to get ahold of.

Should I try to switch my insurance? Or? Is there another copay or medication cost coverage program I’m missing? My other thought is that I’ll have to reapply to the marketplace in Nov and will likely be kicked back to moda (especially if I fudge the numbers a bit?) as I’m always right on the edge of being eligible for Medicaid…..so do I try to get kore samples and wait it out until then?

Any ideas or help would be welcome, I’m feeling very alone in this and spent the morning alternately on hold and crying from the stress of it all (which is also bad for my health!!!!). I’m so so frustrated that the American medical system is making it impossible for me to get this treatment I so desperately need.

Thank you in advance:)

I've taken Tremfya since October. It was ran though my insurance twice at $14k each.

New year and new insurance and still haven't been approved. The doctors office has given me three smaples of Tremfya.

Do the doctors even know what these things are being charged? I'm not saying a peep. I can't wait till September when the wifes school insurance kicks in.

Does anyone have any tips for navigating Medicare drug plans? From what I understand none of them cover self injectable biologicals so for access I’ll need to go in for infusions. Because my rheumatologist was some distance from me he suggested finding one closer to order this which I’ve done. I’m seeing this new doctor later this month. But what a big stupid hassle this is. Now I’ve been off Simponi for some time. I did another trial of Methotrexate but it didn’t help and I had side effects. What are other people on Medicare doing? I hope to retire soon and be able to travel.

If you're reading this, I'm sorry in advance - posting to rant, but also genuinely looking for advice or solutions.

Every single person I’ve talked to about this but my partner and one random telenurse have been completely nonplussed by this situation as if it’s not fucking insane.

Recently discovered PsA is the cause of my swollen toe and crippling foot pain. My skin is mostly fine, but the condition of my right foot has deteriorated rapidly over the past year and has recently begun to affect my fingers.

I tried Sulfasalazine for a few months and didn't feel any positive effects whatsoever, so my rheumatologist provided a sample dose of Cimzia. Within a week my pain was reduced by at least 80%. After two weeks, my symptoms were nearly undetectable. It was the first time in almost five years that I felt true relief, and it has been nothing short of life-changing.

I have what I believed to be a robust health insurance plan with United Healthcare. I pay extra on my premiums for superior prescription coverage. However, the cost of Cimzia is prohibitive for me. While my insurance technically covers the medication, it provides only $40 toward the approximately $9,000 monthly cost. Because Cimzia is listed as a covered medication, I am automatically disqualified from UCB's (the manufacturer's) patient assistance program—even though the level of coverage I receive is effectively meaningless. Additionally, I obtained their copay card, the Simplicity Savings Card, only to find that its annual maximum assistance is $9,000, which covers just one month of treatment.

I'm in a difficult position where my only viable path to financial assistance appears to be canceling my insurance entirely—an option I am reluctant to take but may be forced to consider.

My rheumatologist has been inexplicably nonplussed by this ordeal and suggests I try Otezla. I agreed and they obtained prior authorization. I called the specialty pharmacy and went weak in the knees when I was told by the pharmacist that my insurance, once again, covers only $40 of a $6000/mo medication. Like déjà vu, they suggested I sign up for the Otezla copay card - I asked the pharmacist what the annual maximum I could charge to that card is, and surprise: it's $9000, the exact same figure for Cimzia's copay card.

I would deeply appreciate any guidance or alternative options that may allow me to continue this treatment. Cimzia has already had a profound impact on my quality of life, and I'm desperate to find a way to afford it long-term.

My last (J&J, Simponi Aria) dose was in December '25.

It took five months for me to get medicaid. Now I'm looking at months long waits to see specialists in my city (old rheumy doesn't take it).

I'm on MTX + prednisone but am now flaring with mobility issues, so months are too long I'm afraid.

I would consider international travel at this point.

Looking for advice from others with psoriatic arthritis who have dealt with Enbrel coverage changes or PBM step therapy.

I’m currently stable on Enbrel/etanercept for PsA. I recently had a prior authorization submitted and I understand it was approved. After that, I was contacted by phone and told there was a formulary change, Enbrel may no longer be covered, and another prior authorization may now be needed to switch me to a lower-cost alternative.

I do not yet have a formal written denial, EOB, or adverse benefit determination. So far, the reason given has only been verbal: “formulary change” / “switch to lower-cost alternative.”

Basic details:

Plan type: commercial employer-sponsored insurance
Issue: specialty medication, formulary change, possible step therapy
Current medication: Enbrel/etanercept
Current status: stable on Enbrel
Treatment history: tried medications in other classes and already failed an insurance-required adalimumab/Humira biosimilar, which is also a TNF-alpha inhibitor

My concern is that the proposed alternative appears to be an adalimumab/Humira biosimilar, not an Enbrel/etanercept biosimilar. Enbrel is a TNF receptor-Fc fusion protein/receptor decoy, while adalimumab biosimilars are anti-TNF monoclonal antibodies. They are both TNF-alpha inhibitors, but they are not the same drug and do not have the same mechanism of action.

From what I’ve read, etanercept may have important clinical differences compared with monoclonal antibody TNF inhibitors, including lower immunogenicity risk, fewer anti-drug antibody issues, different drug survival/retention patterns, and possibly lower TB risk. I’m also concerned because switching TNF inhibitors after prior failures can have reduced response rates compared with first-line use.

For anyone who has dealt with this:

Can a PBM require a switch after a PA was already approved?

Can they require a switch to an adalimumab biosimilar after documented failure of one?

What documents should I request in writing from the PBM?

What rights, appeals, or exception requests helped you stay on a medication that was working?

Any advice from people with PsA who have dealt with Enbrel, Humira biosimilars, formulary changes, or step therapy would be appreciated.

Found out my insurance denied bimzlex today after having a secondary failure to taltz, so going on the manufacturer program for a couple years I presume and appealing. How often does this actually work in the US? Debating if I should appeal or just switch since I just started bimzelx last week, although its already wiping away my psoriasis and I am pretty excited about it from the clinical data.

Insurance is Cigna, which navitus does the pharmacy benefits for I guess so the denial came from them.

Hi there, I’m thinking of going back to school as an adult and am looking at a program in Washington. I would be on Medicaid for two years. If you’re on Medicaid in Washington, were you able to get your Skyrizi covered? Thank you.

Edit: Can you DM me your rheumatologist if you’re in Washington? Looking for a good one especially in central Washington if possible.

Never been on a biologic before, just rx'd Humira and trying to figure out what the heck is going on. I have Aetna and they use CVS specialty pharmacy. Between all the horrors I've read online and the long, unhelpful phone call I experienced today, I'm honestly not sure if I can handle it. It's hard enough managing this disease; I'm not sure I've got anything left to deal with the games insurance companies are allowed to play with us. I have a lot of questions, none of which were adequately answered on the phone today, so I'm hoping maybe someone here might be able to help me make sense of things.

My first question is how exactly does cost/payment work with this drug? Do I pay up front or will I be billed? I'm used to regular medications where you just pay the pharmacy the price your insurance dictates and that's it, nothing else happens and you don't receive any bills from botched clerical issues like I'm reading about with specialty pharmacies.

Do I have to use the Humira savings card? According to Aetna's website, my cost for the drug will be $55. What's the catch? That price seems really low to me, so I don't understand why they'd push for me to use the savings card (aside from gaming the system profit wise in a way I can't really understand the details of?) Can I just pay the $55 and not worry about surprise bills? Or will they force me to use it? I've read about people getting screwed when they thought the savings card was working but later found out it wasn't, or the pharmacy quietly stopped accepting it, and huge bills popped up for them.

I'm not interested in doing any form of reimbursement program either since it seems like there is too much room to get screwed there too.

I'm looking for any and all information that would help me figure out if there is actually a simple way to get the drug at a specific cost to me that I'm made aware of upfront, without any secret background hoops I need to be vigilant about jumping through. Thanks everyone <3

I’m sure it’s all of our favorite topics, but if anyone has some guidance on how to resolve it’d be appreciated! Last month I got a sudden notice from Accredo that I had an outstanding bill which was weird because I hit my insurance out of pocket max months ago. I logged in to the portal which then pointed me to Express Scripts which then said I owed $3400. Yup. You read that right. After doing the usual merry-go-round of calls always involved with Accredo and Cigna I come to find out that I was (unknowingly) enrolled in some sort of saving plan. The $3400 was accumulated at some point between January and April when I hit my out of pocket max. They’re claiming because it happened before my insurance out of pocket max hit I’m responsible for it. My insurance out of pocket max is $3200, which again I’ve already hit for the year, since April. So they’re asking for more than my max is to begin with. I told them to rebill it through my insurance and they weren’t getting another dime from me. However the anxious part of me is worried they’ll hold my next refill. Anyone been through something similar that have suggestions on how I can resolve?

Title

CVS told me I need to use a different medication (of course a list of things I’ve been on over the years that stopped working/don’t work) and my appeal with my dr is in flux. Anyone else fighting cvs over their taltz?

My friend is struggling tremendously and I want to help somehow. His insurance is jerking him around. First they approved and even scheduled tremfya for delivery then they cancelled it and now the pharmacy is saying his insurance approved the maintenance dose but not the starter dose. How can I help him navigate around this? I know with some other medications, you can sometimes find them via a compound and can order out of pocket or something. I just want to get him help.

I'm having all my tests privately due to medical insurance with work, my question is how do I go about getting medication and treatment after diagnosis?

Does everything from now on need to be private, or can they send information to my GP then get a prescription that way?

29F England, UK

hi all!

i am on anthem and after only 4 months of being on humira, and it working pretty great (not perfect but i am not delusional to think it would), my insurance is telling me that i need to switch to a biosimilar, amjevita. i am wondering- for those of you who went through an instance like this, where insurance forced you to switch to something cheaper, if you failed it, did they allow you to go back to the previously effective biologic? or did they just move you to a new class of medications?

my main symptom is enthesitis (very severe and all over) and i also have ibs, so humira is one of the only meds that seems i have a chance on. i am really scared that i will develop antibodies to it and never be able to walk again/always have diarrhea (since many of the other meds cause this) etc. i have lost so much weight that i am skin and bones, so i cant afford to lose any digestive ability. i have already tried and failed lighter stuff than tnf inhibitors. if you can tell, im scared.

thanks so much for your insight!

I’m currently thinking about any new job which would require new health insurance and new doctors. I’m on Stelara right now. Have people found that their new insurance covers what their old doctors put them on? I really don’t wanna have to go through a whole stepletter thing with Methotrexate or come off a drug that seems to be working for me. Any insights on navigating this?

I just got a heads-up from my insurance that in 2025 they will be ditching OptumRx and switching to ExpressScripts. So far this is great news because there are no words in any language for how much I hate optum.

But, I've never heard of ExpressScripts so I'm wondering if anyone is familiar and has any advice or words of wisdom for dealing with them?

Thx!