Jane Dotson
It can be frustrating when your insurance company won't cover your medication. There are several reasons why this may be the case, including the medication being seldom used, the availability of a generic alternative, or the existence of a more affordable option. If your insurance company denies coverage for your medication, there are several steps you can take to reduce out-of-pocket costs and possibly get the decision reversed. Firstly, check if there are any generic or lower-cost alternatives that will work for you. You can also explore patient assistance programs or copay assistance programs to help with costs. If these options don't work, you can request an exception from your insurance company or appeal their decision through an internal review process. In urgent cases, you may be able to pay upfront at the pharmacy and submit a reimbursement claim after approval.
| Characteristics | Values |
|---|---|
| Reasons for denial of insurance coverage for medication | The medication is seldom used, there is a generic available, or a more affordable option exists |
| Actions to take | Ask your pharmacist questions about the denial, call your insurer to find out why the coverage was denied, explore generic or alternative medications, request an exception to the formulary, appeal the coverage decision |
| Additional information | Prior authorization is required by insurers before approving coverage for more expensive medications, prescription formularies are developed based on efficacy, safety, and cost-effectiveness of the medications |
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What You'll Learn
Your medication may be too expensive
It can be frustrating when your insurance company won't cover your medication. There are several reasons why this might be the case, and one of the most common is that your medication may be too expensive.
Prescription formularies are developed based on efficacy, safety, and cost-effectiveness. When a medication is deemed too expensive, it may be dropped from coverage. This can happen if a medication is seldom used, there is a generic available, or a more affordable option exists. In such cases, you are often left responsible for the full cost of the medication.
If you find yourself in this situation, there are a few steps you can take to reduce out-of-pocket costs and possibly get the decision reversed. Firstly, see if there is a generic or lower-cost medication that will work for you. You may also qualify for a patient assistance or copay assistance program that can help cover costs. Many drug manufacturers offer assistance based on need, and you can search for these programs by looking up your specific drug. If you cannot find a suitable alternative, you can ask your insurance company for an exception to the formulary so that your medication will be covered.
If your request for an exception is denied, you can appeal the coverage decision. You can start by requesting an internal review, which must be completed within 30 days for medications you haven't started taking yet, and 60 days for medications you are already taking. If your appeal is urgent, you can request an expedited appeal, which must be decided upon within 4 business days. If the internal review is unsuccessful, you can seek an external appeal through your state's insurance regulator or the federal Department of Health and Human Services (HHS).
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Your insurance company may require prior authorisation
If your insurance company has denied your request for medication, it may be because they require prior authorisation. This is a cost-control practice used by insurance companies to determine whether they will pay for certain medications. Prior authorisation requires your doctor to fill out a form explaining why you need that particular medication. This can be a frustrating process for both patients and doctors, as it can take a long time to receive approval, and there is no guarantee that the request will be granted.
If your medication requires prior authorisation, your pharmacy will notify your healthcare provider, who will then provide the necessary information to your insurance company. You should hear back about the decision within two days. If your request is approved, the authorisation will only be valid for a set period, after which you will likely need to reapply.
If your request for prior authorisation is denied, you can submit an appeal. Appeals are more likely to be successful when your provider deems your treatment medically necessary or there was a clerical error leading to the initial denial. It is recommended that you get your healthcare provider's input when building your appeal case. In some cases, you may be able to submit an urgent request for a faster decision.
To avoid the process of prior authorisation, you may be able to pay upfront at your pharmacy and submit a reimbursement claim after approval. Some pharmacies may also allow you to purchase your prescription with a credit card while you wait for prior authorisation, and they will reimburse you if your authorisation is approved within a week.
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Your medication may be considered non-preferred
If your medication is not listed in the formulary, your insurance company may overrule your doctor's orders. This can be frustrating for both you and your doctor. However, you have the right to appeal your insurer's decision. Before starting the appeal process, you can explore the following options:
- Ask your doctor about generics and alternative medications that may be more affordable.
- Request a 90-day prescription and compare costs; a 3-month supply may be a better value than filling monthly.
- Check if you qualify for a patient assistance or copay assistance program that can reduce your out-of-pocket costs.
- Ask the insurance company for an exception to the formulary so that your medication will be covered.
If none of the above options work, you can proceed with the appeal process. If your appeal is for a medication you haven't started taking yet, the insurer must complete the internal review within 30 days. If it's for a medication you've already started taking, the review must be completed within 60 days. In urgent situations, you can request an expedited appeal, and a final decision must be made within 4 business days. If your insurance plan denies your appeal, you can try filing for an independent review through your state's insurance regulator as a last resort.
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There may be cheaper, generic alternatives
If your insurance company won't cover your medication, it may be because there is a cheaper, generic alternative available. Insurance companies have formularies, or lists of covered drugs, which are based on efficacy, safety, and cost-effectiveness. If your prescription is not on this list, you may be able to find a generic alternative that is.
Generic drugs contain the same active ingredients as their brand-name counterparts and are approved by the U.S. Food and Drug Administration (FDA) to treat the same health conditions. They are equally effective and safe but can be much cheaper, sometimes up to 85% less expensive. If you are unsure whether a generic alternative is available, you can ask your doctor or pharmacist, or check with your insurance company.
If you find a generic alternative that you think will work for you, you can ask your doctor to fill out a prior authorization form or write a letter of medical necessity explaining why you need that medication. This may be enough to get the new medication approved. If not, you can ask your insurer for an exception or file an appeal.
If you are struggling to afford your medication, even with insurance, there are other resources that can help, such as prescription discount cards, Medicaid, Medicare, pharmaceutical assistance programs, and nonprofits.
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You can appeal the decision
If your insurance company denies coverage for your medication, you can appeal the decision. The first step is to understand why your claim was denied. This information is usually provided in a document called an Explanation of Benefits (EOB) from your insurer.
Once you know the reason for the denial, you can start the appeals process, which typically has three levels. The first level involves contacting your insurance company and requesting that they reconsider the denial. This may involve a "peer-to-peer insurance review," where your doctor speaks with the medical reviewer of the insurance plan to challenge the decision. It is important to note that some insurers do not allow peer-to-peer reviews after a written appeal has been filed.
If the first-level appeal is unsuccessful, the second level typically involves a review by a medical director at your insurance company who was not involved in the initial claim decision. The goal of this step is to prove that your request should be accepted within the coverage guidelines.
If the second-level appeal is also denied, you can proceed to the third level, which is an independent external review. In this step, an independent reviewer with the insurance company and a doctor with the same specialty as your doctor will assess your appeal to determine if they will approve or deny coverage. During an external review, your insurance company no longer has the final say over whether to pay a claim.
It is important to note that the appeals process can be time-consuming and burdensome, and inappropriate rejections are common. However, it is your legal right to appeal, and many health insurance denials are ultimately resolved through the appeals process. More than 50% of appeals of denials for coverage are successful, and this percentage may be even higher for employer-sponsored plans.
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Frequently asked questions
First, see if there’s a generic or lower-cost medication that will work for you. You may also qualify for a patient assistance or copay assistance program that can reduce your out-of-pocket costs. If neither of these options work, you can ask the insurance company for an exception to the formulary so that your medication will be covered. If you’re still stuck, formally appeal the decision with an internal review. As a last resort, seek an external appeal.
Prior authorization is a restriction put in place by insurance companies to determine whether or not they will pay for certain medicines. It doesn’t affect cash payments for prescriptions. Your doctor will need to fill out a form explaining why you need that medication. If you can’t wait for approval, you may be able to pay upfront at your pharmacy and submit a reimbursement claim after approval.
The reasons can be complex and vary depending on the insurer. Sometimes, there are mistakes or it's a paperwork issue. Other times, there is a more affordable generic option, or a particular medication is seldom used.
