Drug Benefits and Insurance Claim Denials

Prescription drug coverage is a common component of health insurance. However, as with any type of coverage, the insurance company may deny a prescription drug claim for a variety of reasons. A consumer should understand what options are available to appeal a denied drug benefit claim in order to obtain coverage for the needed medications.

Determine Reason

• When an insurer denies a health insurance claim, such as a drug benefit, a consumer needs to determine the reason for the denial. The pharmacist may be able to provide this information or the consumer can contact the insurer to obtain the reason for denial. In some cases, the denial may be due to the doctor or pharmacist improperly coding the doctor's visit or medication. In addition, the insurer may have used the incorrect plan guidelines to deny the prescription. By determining the reason for the denial, the consumer may find that the denial is an error and work with the insurer to gain approval.

Appeal the Denial

• Though many consumers are unaware of the ability to appeal, most insurance companies do have a formal procedure to appeal a denial of coverage. The consumer should contact the insurance company to determine how to file the appeal. When possible, the consumer should include a letter from the doctor explaining the need for the medication as part of the appeal. The consumer should file the appeal as quickly as possible as it may take the insurer some time to review the appeal. If the insurer does not have a formal procedure, the consumer should write an appeal and send it to the insurer for consideration.

Government Regulation

• States have laws protecting consumers from unfair health insurance denials when the doctor orders a specific treatment. Laws vary by state, but the insurance commission in the consumer's state can provide information on that state's laws. If the consumer receives insurance as part of a government program, such as a Medicaid supplement insurance, the government agency that oversees the program may also have guidelines that insurer's must follow. In extreme cases, a consumer should file a complaint with the insurance commission or the state's attorney general.

Work with Doctor

• If the consumer is unable to get the insurer to cover the prescribed medicine, the consumer needs to work with her doctor to find another drug to use. The consumer should obtain a listing of approved medications from the insurer and review the list with the doctor to determine an appropriate alternative to the original prescription. The consumer should take an updated list of approved medications to future doctor appointments to avoid further problems.