Prescription medication prices are increasing every year, and those with financial constraints are heavily dependent on their health insurance to curb their health expenses.
Is your insurance not covering medication? We understand that you become frustrated and confused when you hear that your much-needed medications are not covered by your insurance. You may have no idea what to do or where to get help from in such a dire situation.
What to do when your health insurance doesn’t cover your prescription medication? Fret not. We will walk you through practical steps to help you get your drugs without having to break the bank.
What to Do When Insurance Doesn’t Cover Your Medication?
1. Ask why your drug was denied
You need to know why your insurance won’t cover certain medications. There are many reasons behind the denial.
One common instance is that your insurance coverage has changed, but the pharmacy has not been updated. If that’s the case, simply updating the pharmacy’s information system will solve the issue.
Another possibility is that the pharmacy has no information, like the duration, dosage, or doctor’s signature from your physician, and so your prescription was denied automatically.
Some other reasons are: you have asked for more than the prescribed amount, the prescription has expired, or there is a coding error.
If you find that all the information is right but your prescription is still being denied, you have to ask for an alternative drug.
2. Ask for alternatives
If a drug is not included in your insurance provider’s formulary, they will not cover it. Here, formulary is a list of drugs that can be covered by your health insurance plan.
If the medication is not listed in the formulary, ask your doctor if an alternative belonging to the same drug class can be prescribed.
Another idea is that you can ask for an alternative that belongs to another drug class, but it is known for treating the same condition.
3. Try step therapy
In case you did not know, step therapy is when a health insurance company requires you to try cheaper drugs to see if they work before recommending their more expensive counterparts. This approach helps reduce costs for generic medications.
You can ask your doctor if you can opt for step therapy. However, there is no guarantee that you will be suggested this in every case. Some examples are if there is a high possibility of serious side effects, or the step therapy medication might be ineffective, or if you have tried the step therapy medication before without any success.
4. File an internal appeal
If you initiate the process of conducting an internal or external review, your insurance provider will take their time and review its decision to see if it was fair or not.
Your doctor can help you write a letter or fill out a form. You have to mention things like why you need the drug to be covered in full. You also have to submit the supporting documents provided by your doctor.
If the insurance provider still denies your internal appeal, you can file an independent (external) review with the health insurance regulator in your state. This way, the final decision will be made by the regulator, and your insurance provider will be required to abide by it.
5. Do not forget about patient assistance programs
The good news, there are many patient assistance programs offered by pharmaceutical companies, government agencies, and non-profit organizations. Even if you have commercial insurance, you can still be eligible for these programs and get prescription medication at reduced costs or for free.
Your doctor can help here too by looking into these programs and filling out the applications for a PAP review.
6. Use a prescription discount card
If there is no way out, you have to ultimately pay it yourself. You can use a good prescription discount card, like the Choice Drug Card or a manufacturer co-pay card to help reduce your out-of-pocket costs.
These co-pay and pharmacy discount cards are very easy to use. You can get one online or shipped to your address for free. Then you just have to take the card at your local pharmacy store and submit it to the pharmacist. They will compare prices and find the cheapest option for you.
This way, you can save up to 80% on your prescription medications and enjoy saving for your whole family, including pets.
7. Search for offshore pharmacies
Many do not know about this option, but you can actually use an offshore pharmacy where the same drug (not covered by your insurance) is offered at a much cheaper price, and order it to get it shipped at your doorstep.
To make it work, you should ask your doctor to write the prescription for that drug and then upload or fax the prescription to that offshore pharmacy.
Be careful that you use an authentic and reliable offshore online pharmacy and not a scam.
8. Make use of your compassionate fund
If you are currently employed, you can ask your human resource manager if a compassionate fund is available for you.
Large business organizations often have this program to help their employees deal with financial difficulties.
9. Change your insurance provider
Finally, if you are not happy with your health insurance company, you can simply switch them at the next open enrollment period.
Search for a policy with an extensive formulary or drug list that covers your prescription medications.
However, it is also important to remember that these drug lists are updated regularly, and what covers your needs today may not be available tomorrow.
Wrapping It Up
What to do when insurance denied medication? From checking for simple errors to exploring discount cards, offshore pharmacies, or even switching providers, there are many paths to take when your medication is not covered by your insurance.
As you can see, there is no need to settle for “no” without doing your due diligence. When you get access to the right information, you can easily take control of your health and your wallet.