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My claim for

Humira

was denied.Now what?

We know how frustrating, scary, and confusing this can be, but you’ve come to the right place. First and foremost, it’s important to know that you can appeal. It’s your right!

Didn’t go to medical school or work for a health insurance company? That’s ok. We did. Whether you’re trying to challenge a claim denial, prior authorization, or request a formulary exception, we are here to help.

Claimable can help you appeal.  Why was your claim denied?

What is Humira used to treat?

Humira (adalimumab) (also known asadalimumab) can help reduce inflammation and pain, and slow or prevent the destructive activity of many autoimmune diseases. The conditions it is used to treat include rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), Crohn’s disease, ulcerative colitis (UC), plaque psoriasis, hidradenitis suppurativa, and juvenile idiopathic arthritis (JIA). It's taken as an injection you give yourself every other week. It works by helping block elevated levels of a protein that drives inflammation in your body.

How can Humira help me?
Humira is used to help people who are prone to higher-than-normal levels of immune activity in their bodies. By blocking one of the main drivers of this activity, the immune system calms down and stops attacking your body. This relieves the pain and inflammation caused by that overactive immune system, and helps prevent further damage to your body from that inflammation. People who use Humira generally see improvements in their symptoms, though this varies by condition: * Rheumatoid arthritis: About 60% of people have satisfactory and noticeable improvements within 6 months of starting. 20-30% of people have a “major clinical response”, where their symptoms improve by 70% or more. In combination with methotrexate, this major response can happen with around half of all patients. * Psoriatic arthritis: About 60% of people see a 75% improvement in the severity of their psoriatic arthritis * Anklyosing spondylitis: About 50-60% of people have improvements within 6 months of starting Humira * Crohn’s disease: 55% of people have some improvements with Humira within 6 months of starting, while 40% go into remission. At 12 months, the response rate is 40-45%, with remission for 35% of people. * Ulcerative colitis: Humira has a smaller impact on remission in ulcerative colitis, but has been shown to improve rates of remission by 8-16% * Plaque psoriasis: 70-80% of people have an improvement in their plaques within 16 weeks, while 60-70% clear them completely. After 6 months, these improvements are kept for about 50% of people * Hidradenitis suppurativa: 40-60% of people had at least a 50% drop in abscesses and inflammatory nodules by 12 weeks after starting Humira
What do doctors usually consider before trying Humira?

Autoimmune diseases are often challenging to treat, and different patients respond differently to medication therapies. This means that patients and their doctors often have to work together closely to try multiple different medications before finding what works best to control symptoms and prevent the underlying disease from getting worse or progressing.

One of the cornerstones of the guidelines is the idea of “shared decision making”, where a patient and their doctor go on a journey together to find the right therapy for the patient. This means that the input of the patient is a key part of knowing what’s working and what’s not. That input informs the conversation between the patient and their doctor on when to stay with a medication or make a change.

Here are the details for different conditions where Humira (adalimumab) can be used.

Rheumatoid Arthritis:

* Use: Recommended for patients with moderate-to-severe disease who haven't responded to other treatments like methotrexate.
* Treatment Step: Usually a second-line treatment, used if first-line treatments don't work well enough.

Ankylosing Spondylitis:

* Use: Recommended for patients with active disease despite using NSAIDs (pain relievers). It reduces inflammation and improves symptoms.
* Treatment Step: A first-line treatment for active disease when NSAIDs are not effective.

Psoriatic Arthritis:

* Use: Recommended as a first-line treatment for patients with active psoriatic arthritis. Preferred over other treatments like methotrexate or NSAIDs.
* Treatment Step: Often the first choice over other drugs.

Plaque Psoriasis:

* Use: Recommended for moderate-to-severe plaque psoriasis. It can be combined with other treatments like topical creams or methotrexate.
* Treatment Step: A first-line treatment used right away to help control the disease.

Hidradenitis Suppurativa:

* Use: FDA-approved and recommended for moderate-to-severe cases to improve disease severity and the patient’s quality of life.
* Treatment Step: A first-line treatment for moderate-to-severe cases. Often the first drug doctors try.

Noninfectious Uveitis:

* Use: Recommended for nonanterior uveitis (affecting the middle and back parts of the eye) to reduce flares and improve vision.
* Treatment Step: Used when other treatments, like corticosteroids, aren't enough. Usually not the first treatment but used to better control the disease.

Crohn's Disease:

* Use: Recommended for moderate-to-severe Crohn's disease. It helps reduce inflammation and maintain remission.
* Treatment Step: A second-line treatment, used when other treatments like corticosteroids or immunomodulators don’t work well enough.

Ulcerative Colitis:

* Use: Recommended for moderate-to-severe ulcerative colitis. It helps reduce inflammation and maintain remission.
* Treatment Step: A first-line treatment for patients who need biologic therapy to control their disease.

In summary, Humira (adalimumab) is used for a variety of inflammatory conditions to reduce symptoms and improve quality of life, especially when initial treatments have not been effective. It is often used early in treatment for several conditions.

What are the coverage criteria for Humira?

For Humira to be approved for preventing , you need to have:If this describes your symptoms, and you do not have one of the excluded conditions, you may be a good candidate for Humira approval. However, your treatment history matters. Often you will need to have tried other treatments before your insurance company will approve Humira. The exact requirements can vary depending on the insurance plan, but below are the general guidelines: If you meet the above criteria, you will usually get an initial authorization, which will be active for on average. To continue receiving insurance coverage for Humira it means:

What you can do to help your case?

Make sure your doctor is recording all different types of migraines that you suffer from. For instance, if you have migraines with aura and also have episodes without aura, make sure both are included in your records. Once you get a diagnosis of chronic migraine, however, that difference in coding becomes less important.
Track your migraines. Keep track of how often your headaches happen and their impact on your life (having to miss work or school, skip appointments, avoid driving, etc)
Track the drugs you’ve already tried. This improves your ability to say whether you can skip ahead in the process, especially if your doctor makes note of it.
Note if you have had headaches from your medications, or “medication overuse headaches”. Medications like Aimovig both help reduce headaches and do not cause an overuse headache, meaning they might be the best option for people with medication overuse headache.
Get help writing your appeal. These are complicated documents to write well. But we can take your details, cite the evidence, and improve your chance of turning that denial into an approval. We can help. Start your appeal today.

Learn more about Humira

Claimable makes it easy to appeal denied claims

1

Upload denial letter

All we need to get started is your denial letter and insurance information

2

Answer simple questions

We’ll ask you a few questions about the events leading up to the denial

3

Generate expert appeal

We compose an evidence-based appeal, supported by medical history, clinical research and policy details

4

Submit & support

We mail your appeal and support you through the process

Humira

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References

Ailani J, Burch RC, Robbins MS; Board of Directors of the American Headache Society. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache. 2021;61(7):1021-1039. doi:10.1111/head.14153

Ailani J, Burch RC, Robbins MS; Board of Directors of the American Headache Society. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache. 2021;61(7):1021-1039. doi:10.1111/head.14153

Ailani J, Burch RC, Robbins MS; Board of Directors of the American Headache Society. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache. 2021;61(7):1021-1039. doi:10.1111/head.14153

Ailani J, Burch RC, Robbins MS; Board of Directors of the American Headache Society. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache. 2021;61(7):1021-1039. doi:10.1111/head.14153

Choose a denial
reason to appeal:

No Prior Authorization (PA)

Your doctor did not submit the paperwork required by the insurer to show that you have tried other medications first.

Initial approval ended

The initial approval of Aimovig is sometimes only for a specific amount of time (such a 3 month period).

Renewal request required

The treatment has to be re-approved after a period of time (often one year).

Why It's common for

Humira

Some doctors and their staff do not know which insurance plans require Prior Authorization for which drugs.

How to appeal

Ask your doctor’s office to submit an initial Prior Authorization request to your insurance company. You can also try sending an appeal that details all the treatment options you and your doctor have already tried. That said, a doctor’s office might get a faster result.

Why It's common for

Humira

Insurers want to see that the treatment is working after an initial trial.

How to appeal

Ask your doctor’s office to submit a Prior Authorization renewal to your insurance company. You can also submit your own request, though your doctor’s office might get a faster result. You have to include information on how the treatment has improved your symptoms. This usually means you have fewer migraine days AND you have a "significant clinical benefit" according to your prescribing doctor (sometimes that benefit can be self-assessed).

Why It's common for

Humira

Insurers only want to pay for therapies that continue to work well and give you benefit.

How to appeal

Ask your doctor’s office to submit a Prior Authorization renewal to your insurance company. You can also submit your own request, though your doctor’s office might get a faster result. You have to include information on how the treatment has improved your symptoms. This usually means you have fewer migraine days AND you have a "significant clinical benefit" according to your prescribing doctor (sometimes that benefit can be self-assessed).

Why It's common for

Humira

Insurers sometimes
Do not know your symptoms enough to see how you qualify
Are not following their own rules
Are not following the rules of your state

How to appeal

Document that you are no longer taking that medication.

On a drug that is not allowed at the same time

Some policies do not allow you to be on certain combinations of medications at the same time.

Medical necessity

Your insurance company does not have the information needed to show you meet their criteria. Or, your insurance company knows your history and still thinks you do not meet their rules.

Why It's common for

Humira

5 Some doctors and their staff do not know which insurance plans require Prior Authorization for which medications.

How to appeal

Make sure your symptoms are clear: how severe, how often, and how they impact your life. Check them against the insurance company’s rules to make sure they’re applying their rules correctly. Check state law where you live to see if the rules are different for your area. Not sure where to start? See how we can create a personalized appeal for you in minutes.

Why It's common for

Humira

Some doctors and their staff do not know which insurance plans require Prior Authorization for which medications.

How to appeal

Ask your doctor’s office to submit an initial Prior Authorization request to your insurance company. You can also try sending an appeal that details all the treatment options you and your doctor have already tried. That said, a doctor’s office might get a faster result.

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