Pharmacy And Insurance: When To Inform

When your insurance plan changes, it can be confusing when you first go to the pharmacy to get your regular prescription filled. It's important to let the pharmacist know about your new insurance plan so they can verify your prescription benefit and copays with your insurance carrier. If you don't have your new insurance ID card yet, ask your pharmacist if you can do a partial fill of your prescription medication. Some pharmacies will reimburse you for the cost of your medication if you provide them with your new ID within a certain timeframe.

If you can't get a one-time refill, you have the right to follow your insurance company's drug exceptions process to get a prescribed drug that's not normally covered by your health plan. If your insurer denies your request for an exception, you have the right to appeal the decision and have it reviewed by an independent third party.

What to do if your insurance no longer covers your prescription

If your insurance no longer covers your prescription, there are several steps you can take to try to get the drug covered or reduce your costs.

Firstly, ask your pharmacist why your insurance doesn't approve the medication and if there are any covered alternatives. You should also ask your provider why they prescribed this particular drug, as there may be a less expensive generic option or another treatment you can explore.

If there are no suitable alternatives, you can ask your insurer for an exception. This will require a supporting statement from your doctor, explaining that the drug is medically necessary and that alternatives will have an adverse effect. If your insurer denies your exception request, you can file an appeal. If this is also denied, you can request an independent review through your state's insurance regulator.

If you are still unable to get your medication covered, you may be able to reduce your costs by applying for a patient assistance or manufacturer copay program. These programs can help people save on specific medications, particularly costly, brand-name ones that are often not covered by insurance. You can typically find these programs on the websites of the drug manufacturers or through a site like GoodRx.

Another option is to switch to a different insurance plan that covers your medication. You can do this during the open enrollment period.

Finally, if all else fails, you can pay for the medication out-of-pocket. You may be able to reduce the cost by using a drug discount card or coupon, or by getting a higher-dose prescription and cutting it in half, or requesting free samples from your doctor.

How to get a one-time refill

If you need a one-time refill of your prescription, there are several options available to you. Firstly, check if your prescription has any refills remaining by looking at the label on your last bottle of medication. If there are refills left, you can simply go to your pharmacy and request a refill. If there are no refills left, you may need to contact your doctor or insurance provider.

If you cannot get in touch with your doctor, or if you are travelling, you could try an online or virtual doctor service, which can provide you with a prescription after an online consultation. You could also try going to an urgent care clinic, where a doctor may be able to write you a prescription for a one-time dose.

If you have changed insurance providers, it is important to inform your pharmacy, as your new provider may offer a one-time refill after a change in coverage. If they do not, you can discuss next steps with your doctor, and consider following your insurance company's exceptions process.

If you are unable to get a one-time refill, you may need to pay out-of-pocket for your medication. In this case, it is worth checking if your doctor can provide you with drug samples or prescribe an alternative medication.

The insurance exceptions process

Step 1: Identify the Need for an Exception

First, check your insurance plan details or contact your insurance company to see if a particular medication, treatment, or service is covered. If it is not covered, you will need to request an exception for coverage. This situation commonly arises when there is a lack of in-network specialists or providers for your specific needs.

Step 2: Gather Information and Supporting Documentation

Before submitting an exception request, it is crucial to gather relevant information and supporting documentation. This includes clinical guidelines, peer-reviewed literature, and any data or evidence that demonstrates the medical necessity of the requested medication, treatment, or service. Additionally, you may need to provide details such as your diagnosis, previous treatment attempts, and the rationale for the request.

Step 3: Submit the Exception Request

The exception request can usually be submitted by the enrollee, the enrollee's prescriber, or the enrollee's representative. Contact your insurance company to understand their specific requirements and guidelines for submitting an exception request. Some plans may provide a form to complete, while others may accept a written letter. Make sure to follow the specified process and provide all the necessary information.

Step 4: Understand the Timeline for a Response

After submitting the exception request, the insurance company will review it and provide a response within a certain timeframe. For standard requests, the response time is typically 72 hours, while urgent or expedited requests may receive a response within 24 hours.

Step 5: Handle the Outcome

If your exception request is approved, you will be able to receive the requested medication, treatment, or service as a covered service at an in-network rate. However, if your request is denied, you will need to decide on the next steps. You may choose to pay the full cost of the treatment, try an alternative treatment that is covered, or appeal the decision.

It is important to note that the insurance exceptions process can vary slightly depending on your insurance plan and the specific circumstances of your request. Always refer to your insurance company's guidelines and seek assistance from your doctor or healthcare provider whenever needed.

Appealing a denial

When your health insurance company denies coverage for your medication or treatment, it can be frustrating and scary. However, you have the right to appeal the decision and request a review by a third party. Here are the steps you can take to appeal a denial:

Step 1: Understand the Reason for Denial

Before submitting an appeal, it is important to understand why your claim was denied. Review the denial letter from your insurance plan, which should include detailed information about the denial, the appeals process, and timelines. Common reasons for denial include missing or incomplete information, lack of medical necessity, reaching the coverage maximum, or using an out-of-network provider.

Step 2: Contact Your Insurance Provider

Call your insurance provider to get more details about the denial and your appeal options. Each insurance company has a specific appeals process, so make sure to follow their instructions carefully. Find out about any forms or deadlines you need to be aware of.

Step 3: Involve Your Doctor

In some cases, claims may be denied due to errors or missing information on the claim form. Your doctor can help by resubmitting the claim with the correct information or providing supporting documentation. They can also write a letter explaining the medical necessity of the treatment.

Step 4: Gather Documentation

Collect all relevant paperwork, including the denial letter, original bills, phone call notes, and any supporting documents from your doctor. You will need these for the appeals process.

Step 5: Submit an Internal Appeal

Submit a formal internal appeal to your insurance company, asking them to reconsider their decision. Write a clear and concise letter explaining the service that was denied, why your claim should be paid, and provide supporting evidence such as medical records or letters from your doctor.

Step 6: Await the Response

Your insurance provider is required to respond to your appeal within a certain timeframe. For urgent care appeals, they must decide within 72 hours, while treatment that has already been received should receive a response within 60 days.

Step 7: Request an External Review

If your internal appeal is rejected, you can take your appeal to an independent third party for an external review. This step involves a reviewer from outside the insurance company assessing your appeal. Information on how to request an external review should be included in the Explanation of Benefits (EOB) document or other determination letters from your insurer.

Remember, it is your legal right to appeal a health insurance denial. While the process can be overwhelming, following these steps can help increase your chances of a successful appeal and ensure you get the coverage you need.

How to communicate insurance changes to the pharmacy

It is important to communicate any changes in your insurance plan to your pharmacy to ensure you can continue to access your regular prescriptions. Here are some steps to help you with this process:

Provide your new insurance information

Inform your pharmacist of your new insurance details as soon as possible. Present your new insurance ID card so that they can verify your prescription benefits and copays with your insurance carrier. If you don't have your physical card yet, ask your pharmacist if a partial fill of your prescription medication is possible. Some pharmacies will reimburse you for the cost of your medication if you provide them with your new ID within a certain timeframe (usually around 7-14 days). Alternatively, your pharmacist may be able to run your prescription through the claims system if you have your ID and group number.

Check the pharmacy is in-network

Even if you've been going to the same pharmacy for a long time, contracted relationships can change. Check with your insurance company or on their website to see if your regular pharmacy is still in-network under your new plan. If not, find out what pharmacies in your area are in-network.

Understand drug tiers and prior authorization

Drug lists are typically divided into different categories or "tiers", which determine the copayment you are responsible for. Check with your insurance carrier to see if any of the drugs on their formulary (drug list) require prior authorization. This means that certain requirements must be met or preferred drugs must be tried before your requested drug is approved.

Consider mail order prescriptions

If you take daily maintenance medication, consider getting your prescriptions through mail order. Most insurance carriers will allow for a 90-day fill of your prescription medication at a reduced copay or coinsurance. You will need to complete a mail-order form and ask your doctor for a new prescription written for a 90-day supply.

Communicate with your doctor

Keep your doctor informed about any insurance changes and let them know if you are unable to fill a prescription as instructed. They may be able to provide drug samples or prescribe an alternate medication that is covered by your new plan.

Understand the appeals process

If your insurance company denies coverage for your prescription, you have the right to appeal the decision and have it reviewed by an independent third party. Contact your insurance company to learn more about their specific appeals process.

Frequently asked questions