What do you do if your doctor prescribes you a medication that you really need, but your insurance won't pay for it? Some medications can be very expensive, and you need that insurance coverage to be able to buy it. If the medication is very cheap, you can choose to just pay cash. However, if it is going to cost more out of pocket than you can afford, you need to take other actions. Here are three ways to get around an insurance denial on a pharmaceutical prescription.
1. Ask Your Doctor for Samples
Most doctors are aware of the high price of most prescription drugs. They also know that some patients will be told by their insurance that the drug is not covered. Many doctors keep samples of certain drugs around the office just for this type of occurrence.
Drug company representatives drop off samples with doctors all the time. They do this to encourage the doctors to recommend the drugs to their patients. If you have a sympathetic doctor, you can ask if samples are available to get you through.
Most doctors will be accommodating. Some will even continually give you samples, if you will need the drug long-term. Samples are free, so be sure to call your doctor and ask for them if your insurance turns you down.
2. See if the Drug Manufacturer Participates in a Financial Need Program
According to RXAssist.com, some very expensive drugs are part of financial need programs sponsored by the drug's manufacturer. If you show the manufacturer proof that your insurance will not cover the drug, and provide financial information that shows you cannot pay for it on your own, you may be able to get it for free.
If you do qualify for a financial need program for a certain drug, it will usually be for a year at a time. After that, you will need to go through the application process again if your insurance or financial circumstances have not changed in that time.
Some people continually qualify for financial assistance with their drugs year after year. If you don't know if your drug has a financial assistance program, look it up online or ask your doctor. Information on assistance programs and how to apply is readily available in both places.
3. Appeal the Decision to Your Insurance Company
Most insurance companies, like umbrella insurance through Underwriters, have an appeals process you can use if your claim was denied. With prescription drugs, you will typically need to get a letter from your doctor stating exactly why you need this particular drug (as well as why no substitute drug will do in your case). You might need to send in copies of your medical records, as well.
Once the insurance company looks over your doctor's letter, assesses the doctor's reasoning, consults with their own doctors on the matter, and looks at your medical records, it may give you a waiver. The waiver is a statement of approval for coverage of the drug for a specific period of time.
Just because your insurance company denies coverage for a particular prescription drug doesn't mean you won't be able to get it. All you have to do is get a little creative with the other options you choose. The important thing to remember is that there are definitely other options out there.
Your doctor is the first person to ask about alternatives for getting your prescription if your insurance won't pay for it. Doctors are fountains of knowledge on workarounds for these situations.
Your insurance may also be able to be convinced to make an exception and pay in your case. Don't give up, take action, and your prescription drug can be in your medicine cabinet without you having to pay a fortune for it.