Prescription Wars: The Battle To Get What You Need

What can you do if your health insurance company denies a prescription from your doctor?   While this can often happen with new medications, it can also happen for a drug that you’ve taken for years.  Even if a medication was previously covered, insurance companies can change their drug plan formularies (their list of covered drugs).  The cost for some of these prescriptions out of pocket can be more than $1000 per month.  

Some common reasons for a prescription to be denied are that the drug requires prior authorization or requires step therapy, the medication is not covered as part of the formulary, the pharmacy is no longer in network for your insurance, the maximum number of refills or quantity has been exceeded for that prescription, or plan limitations have been exceeded.

If your health insurer refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party. Here are some steps you can take if your medication was denied.

1. Find out why the drug was denied - You can start by asking your local pharmacist if they can see the reason the prescription was denied.  Sometimes the issue could be a medical coding error, incorrect insurance information, or missing paperwork.  Once the error is fixed or the proper paperwork is submitted, the drug might be approved.  If your pharmacist is not able to provide the reason for the denial, you can call your insurance company directly for more information.  

2. Appeal your case to the insurance company - This process can vary among insurance companies, but it often requires a letter of appeal from your doctor.  The supporting statement from your doctor should explain that your drug is medically necessary and that any alternatives would have an adverse effect or have not worked for you in the past.  There are two types of insurance appeal - internal appeal and external appeal.  Most insurance companies require you to complete the internal appeal process before doing the external appeal.  If your insurance company upholds its initial decision, the Affordable Care Act provides patients with the right to appeal the decision by an outside independent decision-maker, regardless of the type of insurance or state an individual lives in.  If your appeal is for a medication you have not started taking yet, the insurance company must complete the internal appeal within 30 days.  If your appeal is for a medication you are currently taking, the internal review must be completed within 60 days.  In urgent cases, you can request an expedited appeal, in which a final decision must be made as soon as required by your medical condition or within four business days.

3. Research patient assistance programs and discounts - Some pharmaceutical companies offer patient assistance programs that can provide financial assistance or reduced-cost medications to eligible patients.  Your doctor or pharmacist should be able to provide information on such programs.  Be aware that the manufacturer may revoke this benefit at any time.

4. Ask your doctor if there is an alternative medication - For example, a health plan’s formulary may prefer a different brand or a generic drug to treat your condition.  Doctors usually do not know which medications are covered under your specific health insurance drug plan, so it is up to you to ask for other options if needed.  Your physician may be able to provide you with drug samples to help hold you over until the situation is resolved.

5. Find resources through an advocacy organization for your disease - There are multiple national groups and organizations that can help you advocate for your health care.  There are also specific groups that offer support and advocacy for specific ailments, such as migraines, diabetes, cancer, and mental health conditions.  

Remain persistent and keep detailed records of all communication, including dates, names of representatives spoken to, and any reference or case numbers provided.  Remember that you can always reconsider your health insurance plan and drug plan during your open enrollment period.