Why Did My Insurance Deny my Prescription?

 Because healthcare is a complicated web of decisions and payments, the doctor's treatment decision is not the final word, it's only the beginning of the discussion. Medications are particularly vulnerable to denials for a wide variety of reasons, a few of which I will be discussing in this post. 

The insurance who received the claim is not the appropriate payor. 

This is a pretty common mistake that happens at the pharmacy level. Sometimes the information in the pharmacy system has not yet been updated, such as when an insurance plan expires or begins. Sometimes the pharmacy has multiple plans on file to choose from and select the incorrect option. Sometimes it's not clear if the medication is for personal, auto, or work related injury. As the pharmacy does not know they have submitted the claim incorrectly, they cannot necessarily tell you why the medication is denied. Before you panic, be sure to verify the information the pharmacy is using. Make sure that the plan information has been appropriately updated, and that they are billing the correct plan for the treatment.

The insurance did not receive accurate or complete information.

This is another common mistake that happens at the pharmacy level. For example, the doctor submitted medical documentation for a supply of 60 pain pills, but your pharmacy mistyped it as 90. As above, be sure to confirm the information the pharmacy is submitting. Contact your insurance carrier or pharmacy benefit manager to verify what information they have received and if they require additional information. 

The insurance requires prior authorization before they will accept the claim.

There are many reasons why a prior authorization (PA) is required for medications. For example, the medication may be harmful to those over a certain age or with certain health conditions. The medication may be known to interact with other prescriptions you take or may be contra-indicated for your condition. In the case of Medicare, prior authorizations are often required to document that the physician is aware of potential risks and has mitigated them or believes the benefits outweigh the risks. In Worker's Compensation, a prior authorization may be necessary to ensure that the accepted injury requires that strength or dosage for pain management. Sometimes doctors prescribe medications for "off label" purposes, and the insurance carrier requires documentation of why and how that medication is effective for the diagnosis. Your personal insurance may require prior authorizations on medications that are tier 3 or tier 4 for the cost or to ensure more common or cheaper options have been attempted. 

Regardless of the reasons, the insurance carrier is requiring additional documentation from your providers' office. The pharmacy is not part of that process, and it may be necessary for you to contact one or both to start the process, find out the status of the process, or even resubmit lost or misfiled paperwork. 

The medication is Refill Too Soon

The general rule of thumb for medication is 80%, which means pharmacies will begin to seek refills once 80% of your previous fill is gone. This means you can request your refill of a 30 days prescription after 24 days. It also means any request before that 24th day is automatically denied. Insurance carriers have very few allowances for Refill too Soon rejections. They may make an exception in the case of a change of dosage, which means the provider will need to submit a request for prior authorization providing record of the change and why that dosage change was made. They may also make exceptions for Vacation Fills--that is, if you will be away from your regular provider or pharmacy during your normal refill window. 

Sadly, insurance carriers do not provide exceptions for prescriptions that have been lost or stolen. Even with a police report for stolen prescriptions, they may refuse payment on an early fill. In those cases, they consider the patient to be liable for the loss and for any consequences. 

Are you struggling to get a necessary medication filled right now? Does the pharmacy tell you to call the doctor's office and the doctor's office refer you back to the pharmacy? Has the insurance carrier given you the run around? Does the pharmacy benefit manager refuse to give you additional information? If you need help getting your prescription filled, contact us today. We can help you understand why the pharmacy is denying the claim and what you can do about it.