Aetna and humira

[ovenroutine]

Has anyone with Aetna gotten them to approve humira (or a biosimilar) for microscopic colitis? Going through an insurance and health nightmare simultaneously so wondering if anyone found a loophole

[tex]

I doubt you'll find anyone who has received approval (at least recently). Here's why (according to an AI search):

What Aetna’s Humira Policy Says

1. Indications / Medical Necessity Clause
Aetna’s Humira & Biosimilars policy states that only FDA-approved indications and compendial uses are generally considered covered when approval criteria are met. Other uses not meeting these criteria (i.e. off-label uses) are often considered experimental/investigational and excluded.

2. Prior Authorization / Precertification Requirements

Humira typically requires precertification / prior authorization under Aetna’s plan. The clinical documentation must meet the policy’s criteria, generally for approved conditions (e.g. rheumatoid arthritis, ulcerative colitis, Crohn’s disease). Off-label uses typically face more scrutiny.

3. Formulary & Coverage Changes

As of April 1, 2024, Aetna is removing Humira from many commercial pharmacy formularies, replacing it with biosimilars as preferred adalimumab products. Because of that removal, coverage for Humira is becoming more restrictive, especially in commercial plans.

4. Exception / Appeal Procedures

Aetna has processes for medical exception or formulary exception requests, where a plan member or physician can request coverage for a non-formulary drug (or off-label use) based on compelling evidence that no suitable alternative exists. For specialty medications, Aetna also has a specialty medication precertification form requiring clinical information to justify therapy.

Bottom Line & Likelihood

Because microscopic colitis is not generally recognized as an approved use for Humira, Aetna would likely reject the request as experimental/investigational unless very strong evidence is presented. Even if a doctor appeals or requests a medical exception, success would depend on:

1. Clinical documentation showing failure of standard therapies (budesonide, immunosuppressants, etc.)
2. Strong evidence in that particular patient’s case
3. The specific Aetna plan (e.g. Medicaid, employer plan, commercial) and its flexibility
4. Whether the plan still has Humira on formulary (many are removing it in favor of biosimilars)

So, in practice, approval would be rare and require a substantial case, not a standard approval.

In my strictly unprofessional opinion, you would have a higher chance of successful treatment results by using tirzepatide (specifically, Mounjaro, rather than Humira), but unfortunately, the chances of getting it approved by Aetna probably wouldn't be any better, unless your Aetna plan is generous, or has flexibility regarding off-label
use.

I hope thos helps,

Tex