Understanding Insurance Processing Times For Pharmacies

When visiting a pharmacy, it is important to know that your health insurance can help cover the costs of prescription medications. Pharmacies require your insurance information to determine your copayment amount, that is, how much you pay and how much is covered by insurance. This is because insurance companies have a list of preferred drugs that have been designated as safe and cost-effective. If your prescription requires prior authorization, you or your pharmacist should contact your doctor so that they can provide the necessary approval or select a different medication that does not require prior authorization. This process can be time-consuming, with patients sometimes waiting days, weeks, or even months for approval.

Prior authorization

The prior authorization process can range from a few days to a few weeks. This can depend on the urgency of getting the medication, the speed of the provider and insurance communicating, and the complexity of completing all the required steps. Once approved, the prior authorization typically lasts for a defined timeframe, usually 12 months. The approval duration is determined solely by your insurance. If your insurance changes, a new prior authorization may be required.

If your prescription requires prior authorization, the pharmacy will notify your healthcare provider. Your provider will give the necessary information to your insurance company, which will then decide whether or not to cover your medicine. You should hear back from your pharmacist about their decision within two days. You may be able to speed up the process by speaking with your insurer directly and submitting an urgent request.

Insurance company appeal process

When a patient goes to a pharmacy to fill a prescription, they may be told that their insurance company will not cover the medication. This is often due to a process called prior authorization, where insurance companies require approval from a physician before covering certain medications. In such cases, patients may initiate the insurance company's appeal process.

The appeal process typically begins with an internal appeal, which must be filed within a specified timeframe. For example, if the appeal is for a service that has not yet been received, the internal appeal must generally be completed within 30 days. If the service has already been received, the timeframe may be extended to 60 days or more. During the internal appeal process, relevant documentation, such as Explanation of Benefits forms and letters detailing denied payments or services, should be submitted to the insurance company. It is important to maintain thorough records, including notes and dates from any phone conversations or correspondence with the insurance company or healthcare providers.

If the internal appeal is denied, individuals have the option to request an external review. This process involves seeking an independent assessment of the insurance company's decision. In urgent situations, an external review can be requested concurrently with the internal appeal process. The insurance company's final determination should provide instructions on how to initiate the external review process.

It is important to note that the appeal process can be time-consuming, and patients may experience delays in receiving their medications or treatments. Physicians play a crucial role in this process, as they often need to fill out paperwork and provide additional information to support the appeal. However, insurance companies may take their time to respond, leading to prolonged waiting periods for patients.

In-network pharmacies

Insurance companies usually have a broad network of pharmacies, including both national chains and independent shops, that their customers can choose from. This ensures that their customers can easily find a convenient place to fill their prescriptions. For example, UnitedHealthcare offers a large network of retail chain pharmacies and independent pharmacies through its pharmacy service provider, Optum Rx. Aetna Medicare also offers a broad network of over 65,000 pharmacies, with more than 23,000 preferred pharmacies.

To find an in-network pharmacy, you can check the back of your health insurance ID card or go to your health insurance company’s website to find their customer service phone number. Some health insurance companies may also send you printed resources or offer an app you can download to find in-network pharmacies. Before filling your prescription, it is important to confirm your plan’s specific coverage details and check with your pharmacy for any prescription refill process requirements.

In some cases, you may need to use an out-of-network pharmacy. This may be because there is no in-network pharmacy nearby or that offers 24-hour service, or because the drug you need is not stocked at an in-network pharmacy. Before using an out-of-network pharmacy, be sure to understand your insurance benefits as you may have limited or no coverage.

Drug tiers and formularies

A formulary is a list of generic and brand-name prescription drugs covered by your health plan. Non-formulary drugs typically only include brand-name medications and come with high out-of-pocket expenses. Your health plan may only help you pay for the drugs listed on its formulary. Formularies are reviewed and updated each year to help ensure your safety and to provide cost-effective choices.

A Prescription Drug List (PDL) or formulary categorizes drugs into tiers, usually three to five of them, based on how much they cost you. Drugs on Tier 1 are the cheapest and are often generic versions of brand-name drugs that are in higher, more expensive, tiers. Your insurance plan may not cover every possible medication. It depends on whether your PDL is open or closed. With an open formulary, your health plan covers any drug approved by the FDA. The tier a drug is in tells you how much it will cost. If you look at your Summary of Benefits and Coverage, you’ll see the copay or coinsurance amount for each tier under your health plan. Generally, the higher the tier, the higher the cost of the drug. For example, a 3-tier formulary will have the lowest-cost drugs in Tier 1, higher-cost drugs in Tier 2 and the highest-cost drugs in Tier 3.

If your drug isn’t listed within any tier, it may mean that it’s not covered under your insurance plan. In this case, it may qualify for a discount with your insurance company's drug discount program, or you will have to pay the full price for the medicine. If you are prescribed a medicine not covered under your plan, you can ask your prescriber if there are options available. Or you can have your prescriber contact the insurance company for approval.

If your prescribed drug is not covered under your plan, there are steps you can take to get your plan to cover a non-formulary drug. Every insurer has an “exceptions process.” You will need to fill out and mail paperwork or submit a form online. While the exceptions process may vary from one company to another, they all have the following in common: Your healthcare provider must confirm you need the drug they prescribed. Your doctor must state that your plan’s covered drugs won’t treat you as effectively as the prescribed medication. Your physician believes that your plan’s covered drugs may harm you. Your plan only covers the drug at a lower dosage that’s not effective for you. If you are overweight or obese, for instance, you may need a higher dose that’s not covered by your plan. Ask your health plan about temporary coverage during the exceptions process. Your insurer may agree to cover the drug until they make a decision.

Generic drugs

According to the FDA, generic drugs may cost 80-85% less than brand-name medications. Drugs with six or more generic competitors can lead to a price reduction of 95%. The use of generic prescription drugs in place of their brand-name counterparts has led to significant cost savings for the healthcare system and consumers. In the United States, the use of generic drugs saved $192 billion in one year.

Despite the benefits of generic drugs, some consumers are reluctant to use them, believing they are inferior to brand-name drugs. This perception is incorrect, as generic drugs must meet stringent FDA requirements for safety, effectiveness, and quality. FDA staff continually monitors all approved drug products, including generics, to ensure they are safe and effective. Physicians also play a role in promoting brand-name drugs over generics. Doctors may prescribe brand-name drugs instead of generics due to their familiarity with the medication or because they believe it is in the best interest of the patient. However, this can result in higher out-of-pocket costs for patients and higher health insurance costs.

To address this issue, some health insurance companies are requiring members to take generic drugs instead of brand-name drugs to lower costs. This practice, known as "non-medical switching," can be frustrating for patients who have found success with a brand-name medication. However, it is important to note that generic drugs are safe and effective alternatives that can provide significant cost savings for both the healthcare system and consumers.

Frequently asked questions