After switching health insurance plans, John's new plan refused to authorize a renewal for an effective biologic infusion treatment, insisting he restart a step therapy process, which required retrying and (re)failing multiple medications. Knowing the toll and risk this would cause, his rheumatology practice worked tirelessly to appeal—submitting multiple prior authorization requests, making 16 calls, and writing a letter of medical necessity. Despite their efforts, the insurer delayed reviews and notifications, leaving both patient and provider in limbo. As a result, John experienced a 4-month gap in infusions, typically taken every 6 weeks, causing severe pain, difficulty working, and social isolation.

John was referred to Claimable by his rheumatologist, and was able to generate, review, and submit a patient appeal all in the same day. Claimable’s appeal strategy focused on proving the step therapy requirements had been previously met and highlighting applicable laws mandating exceptions to step therapy guidelines be granted for patients in similar situations. The appeal also emphasized the his right to a fast and fair review (72 hours), copying appropriate regulators and executives to maximize reach and impact.