You still have options, even if the medication is denied. The first step is filing an internal appeal, where you ask your insurance company to conduct a full and fair review of its decision. Start by calling your insurance company to find out exactly why you received a rejection.
“Many times, it’s for a simple reason, such as missing documentation showing that other medications were tried and failed or the provider forgetting to include the official diagnosis with the prescription,” says Skirrow.
There’s a good chance your insurance company will reverse the decision, as long as the internal appeal was submitted correctly and addressed the reasons coverage was denied the first time, Skirrow says. Up to 80 percent of initial prior authorization denials are overturned, one recent report showed.
If your internal appeal is denied, you can also pursue an external review. That’s where an independent third party — not your insurance company — reviews your case and decides whether the medication should be covered. The process for external reviews varies by state. “Because of this, it’s important to review the applicable state- or plan-specific guidance and follow the required steps when submitting a request,” says Skirrow.
If all of your appeal options have been exhausted and the medication is still denied, pharmaceutical company patient assistant programs can help you avoid paying the full cost of treatment out of pocket.
“If applying for one of these programs, it is important to keep documentation of the insurance denial and any appeal attempts, as this information is often required as part of the application process,” says Skirrow.
Read the full article here
