Prior auth denied for "maximum drug cost exceeded" on ACA-compliant plan

I have severe, steroid-refractory Crohn’s disease and tried/failed previous therapies. I failed Stelara at 8 week dosing, but quickly went into remission after changing to 4 week dosing. At the time insurance did not fight the prior authorizations for the initial 8 week or later 4 week dosing request. We have documentation of everything: many endoscopies, MRIs, lab work, etc.

This year, the same insurance company has decided to fight the prior authorization. Their official reason is “cost limit exceeded.” I have an ACA-compliant plan through my employer, Stelara is on their preferred biologic drug list, and I have always filled it at their required mail order specialty pharmacy: Accredo.

Representatives at the specialty pharmacy and insurance company have said that I exceeded the maximum cost cap that my insurance plan is willing to cover for Stelara and I’m out of luck. I’m furious because this medication has worked very well for me and if they kick me off Stelara, it’s going to seriously affect my quality of life and put me in the hospital again.

What can I do?