Q&A Topics

Thursday, May 5, 2011 10:27:17 AM

Why does my health insurance pay for some of my prescriptions but not for others?

Prescription drugs can be denied by health insurers for many reasons, such as the following:

1. Your health insurance plan excludes it. Certain prescription drugs, like acne medication, may not be covered by your plan.

2. You're refilling too soon. Your plan probably allows you to refill a prescription only after a certain amount of time. It's calculated by the dosage.

3. Your prescription requires "medical necessity" or "step therapy." In other words, you must get a letter of medical necessity from a physician or try other medications first.

4. Your prescription involves "duplicate therapy." In layman's terms, that means you previously were prescribed a similar medication.

5. Your prescription exceeds a quantity limit. Some prescriptions have such limits, which are based on FDA dosing guidelines and extend over a rolling 30-day period. If your doctor prescribed more than the customary supply, the prescription may be rejected without supporting documentation from the doctor.

If your prescription has been rejected by your health insurance company, you must determine the reason and then work with your pharmacy program and physician to allow your prescription to be approved.

Here are some other recommendations for handling a prescription denial:

• Make sure the rejection isn't due to timing. If you’re prescribed a one-a-day pill and have a 30-day supply but you're trying to refill it on the 21st day, this could be the problem. Your health insurance company has noticed that you have enough of the medication and are refilling it too early.

• Ask the pharmacist why your health insurance company isn’t paying for medication. The pharmacist should be able to offer details.

• Once you get the denial details, call your health insurer and ask which company is your pharmacy vendor and get that vendor’s phone number. The pharmacy program's number may be listed on the back of your health insurance card. The pharmacy vendor manages prescription benefits for your health insurer.

• Call your plan’s pharmacy vendor and ask the right questions. Your aim here is to get all the appropriate information you need to bring back to your doctor and get access to the proper medication. Quiz the pharmacy vendor about why the prescription was rejected, whether there is another drug that could be substituted for the one that was rejected, and what dosage per day or quantity per period could be covered.

• When speaking with the pharmacy vendor, request a copy of the specific form you’ll need to submit to qualify your prescription for coverage.

• Ask for an online link to or a copy of the pharmacy vendor's "formulary," or list of prescription medications. Giving this document to your physician might help prevent any medication coverage issues.

• Once you've assembled the information from your pharmacy vendor, give it to your doctor. Your doctor either can switch your medication to an equivalent alternative or can fill out the form, explaining why you can’t be prescribed the alternative.