Every year, the average American spends around $1,200 on prescriptions. Some drugs, such as cancer medications, can cost tens of thousands of dollars.
Given these facts, it’s easy to see why you need good prescription medication coverage. Having a “good” insurance plan doesn’t guarantee that the cost of your medication will be covered though.
Many Americans only discover this when they get their prescription filled. Sometimes, insurance companies de-list medications they covered before.
If you’re wondering what to do when insurance denied medication costs, try one of these five methods. They could help you get coverage for all or part of your medication.
1. Swap Your Prescription Medication
Why did your insurance provider deny your medication claim anyway? This is a question many people ask after the costs for a medication go up. Others are left wondering why a previously covered medication is no longer covered.
Companies work hard to keep the cost of insurance down. One way to do this is to negotiate with drug companies. Some insurers will have lists of “preferred” brand-name and generic medications.
As insurance companies negotiate, their list of preferred providers and medications changes. That may be one reason a drug goes from being entirely covered to only partially covered or not covered at all.
Other factors include new research about the effectiveness of medications and new generic drugs.
If your insurer de-lists your prescription medication, ask your doctor about switching. Most insurers offer drug formularies. These lists include alternatives for medications they don’t or no longer cover.
In some cases, another drug is just as effective for a patient. This is often the case with generic drugs, which are as safe as name-brand medications. Patients and insurers often end up paying much more because of the name on the box.
2. Step Therapy Moves through Tiers
If you and your doctor know alternatives won’t work for you, you need to convince the insurance company too. One way to do that is with step therapy.
Most insurers divide up medications into a drug formulary with four or five “tiers.” Prices and coverage vary by tier. Tier 1 drugs are most likely to be covered, while those in the highest tiers are less likely to be covered.
- Tier 1: The lowest-priced drugs, usually generics.
- Tier 2: Preferred generic and brand-name drugs.
- Tier 3: Non-preferred brand-name drugs.
- Tier 4: The highest priced medications, often those used for treating rare illnesses.
A step therapy approach allows you to move through these tiers. You’ll work with your doctor and begin with a lower-tier medication. Your insurer is more likely to cover these medications.
If this medication doesn’t work for you, your doctor can prescribe a medication from a higher tier. Step therapy provides evidence that the patient needs a certain drug for effective treatment. Insurers are more inclined to pay when there’s medical proof you must have one drug over another.
The other benefit of step therapy is that it can find an effective medication for a lower cost. Some doctors prescribe certain medications because of incentives from pharmaceutical companies. They may not have considered other alternatives that could be as good.
3. Ask for an Exception for Your Medication
Some patients have already spent time trying other medications. If you’re one, you know step therapy isn’t going to work. You also know switching medications isn’t an option for you.
If the insurance company won’t budge though, you can try filing an exception. Your doctor will be able to file this through your health plan.
An exception argues that this particular medication is medically necessary. It may be the only effective drug on the market for a rare disease. You may also have tried other medications before and know this medication is the only one that works.
In most cases, it only takes a few days for an insurer to approve or deny an exception.
4. Appeal a Decision
If your insurer denies your application for an exception, you can appeal. You’ll start with an internal appeal. You and your doctor will supply evidence that the medication is medically necessary.
If the appeal is still denied by the insurance company, you can apply for an external review. The insurance regulator in your state should have a program to handle these requests.
If your state doesn’t have an external review process, you can send your appeal to the Department of Health and Human Services.
You can view here information about the external appeals process.
5. Be Sure to Shop Around
Sometimes, it’s impractical to go through the lengthy appeals process or to try step therapy. You might be better to shop around and see if you can find a lower-cost alternative.
Drug prices can vary widely between pharmacies, even within the same zip code. Some pharmacies are able to negotiate better prices. This could mean any coverage you do have goes farther.
A prescription discount card can also help you manage out-of-pocket costs.
If you’re using a generic drug, you might get a better deal by not using your health insurance. Some large retailers offer generics for very low prices.
Another way to shop around is to find a new insurance provider. Another company may offer better coverage for your prescription. If they don’t, they might be more willing to grant an exception.
It can be difficult to shop around if you have a pre-existing condition. Weigh your options carefully. Ask plenty of questions before you make the switch, and always read the fine print.
Finding Health Insurance That Fits
You still have options when an insurer denies a claim for a prescription medication. It’s a good idea to check your plan on a regular basis to make sure it’s meeting your needs.
Prescription medications aren’t the only reason have health insurance. Check out our other articles to learn more about how the right health insurance can help you live better.