Tips for Consumers: Your doctor has diagnosed a condition, and the good news is there is a medicine that can treat it. The bad news is that your insurance doesn't cover the medicine.
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When your insurance company won't cover a medicine, it may be because the medicine is not on the insurance plan's "formulary," or list of medicines covered by the plan. Below are tips to help you gain access to the medicine that is best suited for your health needs.
Your options include:
- Ask your doctor to request an "exception" based on medical necessity
- A doctor can request that the plan cover the medicine "by exception," even though it is not on the plan's formulary if he or she feels that another medicine will not work as effectively for you, or if, for example, you are allergic to the other medicines on the formulary.
- Ask your doctor if a different medicine - one that is covered - will work for you
- Sometimes, another medicine - one your insurance will pay for - will work to effectively treat your condition. Discuss with your doctor the risks and benefits of taking a different medication.
- Pay for the medicine yourself
- Sometimes there is not a significant difference between the cost of the medicine if you pay for it yourself and your insurance plan "co-payment," (the cost you are required to cover as part of your plan). In rare cases, it is actually less expensive to pay for the medicine without plan coverage than with plan coverage.
- File a formal, written appeal
- If your doctor requests an exception and it is denied, you can further appeal that decision by submitting a letter of appeal to your insurance company. For more information about what information to include in your letter see a sample letter, visit www.YourPharmacyBenefit.org and select "Medicare" or "Private Insurance" and then click on "Use Your Plan."
Writing a Letter of Appeal
If you or your doctor requested an exception but your insurance still will not cover the medication, then it is best to submit your appeal in writing. This way you also have a written record of the actions you took and the dates on which you took them. Be sure to include the following information in your appeal letter to your insurance plan:
- Your name
- Your address
- Your phone number
- You ID number
- The date
- The date you sought to fill the prescription
- The name and address of the pharmacy where you took the prescription
- The name, address and phone number of the doctor who wrote the prescription
You should also:
- Include a copy of either the receipt, if you paid already, or the prescription, if you didn't. If you don't have either of these items, list the exact name and dosage of the medication for which the prescription was written.
- Clearly state that you wish to formally appeal the denial of drug coverage.
- State that the insurance company has permission to contact your doctor's office if medical information is needed to consider your appeal. (Be sure to let your doctor's office know that they may get a call.)
- Indicate that you expect the plan to tell you about all steps you may need to take for them to process your appeal. Also ask them to tell you how you can appeal further if they deny this appeal.
- Ask them to clearly describe their decision and the basis for that decision when they respond in writing.
To see a sample letter, visit www.YourPharmacyBenefit.org and select "Medicare" or "Private Insurance" and then click on "Use Your Plan."