“I’m sorry, but your insurance doesn’t cover this prescription. Would you like to pay out-of-pocket?” Those are discouraging words, for sure, but they don’t have to be the final words. As a health plan enrollee, you have the right to follow your plan’s procedures to show why the medication you’re seeking is the most effective one for your condition and should be covered. To start:
Whether you’re advocating with your insurance company or someone else is taking the lead, be informed. The following questions and answers describe how private insurance companies and public health insurance programs determine drug coverage as well as their general appeal procedures. Timelines vary, but most plans offer expedited appeals if your prescriber can prove your need is urgent.
The pharmacist said the drug prescribed for me isn’t on my insurance plan’s formulary. What’s a formulary?
A formulary is a list of drugs your insurance plan approves and prefers for certain medical conditions. Drugs on a formulary are usually grouped into tiers according to cost. If you have a choice of healthcare or prescription plans, you can select one that covers your current medications. However, drugs can be dropped from or added to formularies at any time.
What if my plan offers a generic or biosimilar drug instead of the name brand drug prescribed?
Whether to accept a generic or biosimilar drug, or appeal to try and get coverage for the brand name drug, is a decision you and your doctor will make after reviewing the options. Biosimilars and generic drugs are more affordable versions of brand name drugs and have been approved by the U.S. Food and Drug Administration on the basis of their close similarity to the branded one. However, they may not be identical.
What are some of the reasons insurers give for denying coverage for a prescribed medication?
How do I know why my insurer wouldn’t cover my prescribed drug?
You’ll learn why from your insurer in an Explanation of Benefits or a denial letter you receive in the mail. It should also tell you how to appeal the decision and give timelines. If you get answers verbally from your pharmacist or by calling your provider, make sure you get the denial in writing, too.
What can I do to get my health insurance provider to cover the drug that was denied?
First, follow your insurance company’s formulary exceptions process. Usually, your doctor must confirm to your health insurer that the drug is appropriate for your medical condition based on one or more of the following:
If there’s a limit on the number of doses allowed, your doctor must provide evidence the allowed dosage hasn’t worked for your condition, or show why the drug likely won’t work for you based on your physical or mental makeup. In addition to your medical history relevant to the case, include peer-reviewed articles from your doctor’s professional journals or magazines that support the treatment your doctor recommends. Also, your plan’s Evidence of Coverage contains detailed guidelines that explain what the company considers medically necessary. Use these guidelines to help explain why a particular drug is a medical necessity for you.
My insurer denied my request for an exception. Now what do I do?
If your plan offers no more internal reviews, file for an external review with your state’s insurance regulator. If your state doesn’t have an external review system, the Department of Health and Human Services or an independent review organization will oversee the process. A final decision can take up to 60 days and is free if handled by HHS, but may cost a small fee if it’s handled by your state or an independent review organization. The information on your EOB or on the final denial of the internal appeal by your health plan gives you contact information for the organization that will handle your external review.
Are there resources outside of my doctor’s office that can help?
If you're covered by a job-based health plan, contact the Employee Benefits Security Administration, U.S. Department of Labor, online at askebsa.dol.gov or call 866-444-3272. Your employer’s human resource department may also offer assistance. The nonprofit Patient Advocate Foundation offers free healthcare appeal assistance to individuals who meet certain criteria. Call Case Management toll-free at 800-532-5274 or fill out an application online at patientadvocate.org.
How do I appeal a drug coverage denial if I get my health insurance through federal and state programs?
For details, forms, and assistance regarding all Medicare/Medicaid appeals contact:
The following summaries cover the basics in the Medicare/Medicaid appeal process:
Original Medicare
Original Medicare includes Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). Part B covers most drugs that can’t be self-administered (such as infusions at a medical clinic). If you’ve been denied access to a drug under Part B, look for information about your appeal rights in the Medicare Summary Notice mailed to you every three months. If you decide to appeal, ask your doctor for supporting information that may help your case. Keep a copy of everything you send to Medicare as part of your appeal and document all correspondence. The appeals process has five progressive levels, but approval can be granted at any level.
Medicare Advantage with Prescription Drug Coverage (Part C) and Medicare Prescription Drug Coverage (Part D)
To obtain a drug not included on a plan sponsor's formulary, or to obtain a formulary drug that involves requirements you need to bypass (such as step therapy, prior authorization, and quantity limit) start by requesting a formulary exception. So you don’t have to repeat the process next year, ask the plan to approve coverage for as long as you’re in the plan. Your prescriber must submit a supporting statement to the plan sponsor, explaining why the requested drug is medically necessary for you or why you should be permitted to bypass the requirements. The statement must also indicate the nonformulary drug is necessary for treating your condition because all covered Part D drugs on any tier would not be as effective or would have adverse effects. If relevant, the statement can also include:
If the formulary exception is denied, you’ll get a notice explaining why, along with instructions on appealing. If you appeal, ask for a copy of your case file.
Medicaid
Under federal law, states can decide whether or not to provide prescription coverage for Medicaid recipients. As of 2018, all states do. All FDA-approved outpatient drugs made by manufacturers who enter into a rebate agreement with the Secretary of HHS must be covered by states that provide Medicaid prescription drug plans. Each state has its own Medicaid formulary, usually divided into “preferred” or “nonpreferred” drugs. Preferred drugs do not require special authorization to use (except in certain circumstances). To get prior authorization for nonpreferred drugs, your doctor must present evidence supporting why the drug you’ve requested is better for your condition than a preferred drug in the same category. Sometimes you may have to try a particular drug or two (step therapy) before getting prior authorization for the drug you want to use. Usually you must pay more for drugs on the non-preferred list. You have the right to appeal if the authorization is denied. Follow the instructions provided by your plan.