Your prescription isn’t covered. Now what?
Don’t panic. The process can be time-consuming and challenging, but there are steps you can take with your doctor and insurance company to get the medication you need.
Ask why the drug is denied.
Small errors can cause big problems. The answer may be simple. The pharmacy may be missing information from your doctor, or may not have your most up-to-date insurance information. Other questions to ask include: Is a prior authorization required? Does the medication require step therapy? Is the drug in question no longer included in your insurance formulary? Did your insurance company move your drug to a higher tier and now will only cover a portion of the cost?
Ask for alternatives.
If the drug is excluded from your insurance provider’s formulary, ask your doctor if there is an alternative in the same drug class that can be prescribed in its place. In many cases, there is. Another option is to ask if there is an alternative medication in a different drug class that will treat the same condition.
Consider step therapy.
Sometimes insurance denies covering a drug because it requires step therapy first. It may agree to cover the cost of the drug after the patient tries (and fails) step therapy. Talk to your doctor about which step therapy is right for you. In some cases, your doctor may support it. In other instances, they may recommend against it.
Ask for an exception.
If an alternative drug isn’t possible or your doctor recommends bypassing step therapy, you can ask them to help you file an exception request with your insurance provider for the drug that was originally denied. Your doctor can submit paperwork to your insurance company documenting why you cannot take the formulary’s preferred medication and must have one that does not appear on it.
Initiate an internal appeal or external review.
If you’ve done everything right, and your insurance provider still denies covering the drug, you can file an internal appeal (requesting the insurance company conducts a full and fair review of its decision). Work with your doctor to fill out the necessary forms or write a letter. If insurance denies the appeal, you can file an external (independent) review with your state’s insurance regulator, which will make the final decision.
Ask about patient assistance.
Many pharmaceutical manufacturers, non-profits and government agencies offer patient assistance programs (PAPs) that help patients afford medications by providing drugs at reduced or no cost. Benefits and eligibility vary by PAP, but they are worth looking into. Work with your doctor to find out if there is an assistance program for the drug they prescribed.
Try manufacturer co-pay cars or GoodRX.
GoodRX and manufacturer co-pay cards may lower the out-of-pocket costs to consumers. You are not required to have insurance to use GoodRX, but co-pay cards are only available to those with commercial or private insurance. Co-pay cards typically offset costs of brand name medications that do not have a generic alternative, while GoodRX offers coupons for both brand names and generics. For a $10 monthly fee, you can enroll in GoodRX Gold, which offers more than 1,000 prescriptions for less than $10 and free home delivery on more than 950 prescriptions.
Switch insurance providers.
If all else fails, consider switching insurance providers at the next open enrollment opportunity. Find a policy with a formulary that covers your medication. Keep in mind that formularies change often, however.
Talk to your doctor.
The best thing you can do is to explore your options with your doctor. If you’re facing drug denial, there are always different options you can take.
Source: IG Living Magazine, June-July 2024 Issue, Rachel Maier, MS