Medical Challenges

Tips to Mitigate Issues

Medication denials by insurers are an unfortunate reality that can occur. It is helpful to understand why many denials are made and what can be done to prevent them. Usually, medication denials are associated with a medication that is not covered under your current drug plan, also known as a formulary or pharmacy drug list (PDL). These lists will also let you know what tier medications are and what will be required to approve your medication. If you are in a situation where your medications have been denied, do not panic. Here are some helpful steps to understand the denial.

  1. Call your insurance company to clarify why the medication was denied.
    1. Were there any coverage restrictions? One such restriction may be a prior authorization (PA). The PA approval process on average is 72 hours. Urgent PA requests may be completed within 24 hours.
    2. Is there an emergency fill option while the denial is being approved?
    3. Is there a quantity restriction? This is the amount (number of pills, for example) of medication prescribed. Some plans will only cover a certain amount per month.
    4. Does this medication require step therapy?
  2. Is this medication included in the formulary (or PDL)? If not, what are the formulary exceptions to this medication on your specific plan?
  3. Is there an alternative to this medication that will be covered? For example, when your provider prescribes the brand name (Sabril®) but your plan will only cover generic (vigabatrin). If this substitution is allowed, then call your prescribing providers office to let them know as soon as possible. Never assume your providing office will be notified of this denial in a timely manner.
  4. Are compounded medications covered under the current plan for “off-labeled” use? Compounded medications are ones that undergo a transformation within the pharmacy to change their delivery method – for example, a medication that is typically taken in its pill form may be ground up into a fine powder and reconstituted as a drinkable liquid.

Emergency Medication Needs (Help!) One way to prevent delays in medication refills is keeping track of when your medications can be refilled and starting the refill process as soon as you can, which may include needing another round of prior authorization. However, even the most precise planning may not prevent running low on medication, creating a difficult situation outside of your control. It is essential to know how to overcome this as soon as possible. Have a clear plan discussed with your prescribing provider at the time new medications are prescribed to what you should do in case you find yourself in the situation. Many individuals end up in this situation usually from a prolonged prior authorization process or from an unexpected denial. Rarely, lifesaving medications can experience a drug shortage. Medication drug shortages are tracked by the FDA and can be located here. Here is a guide on Emergency Medication Checklist if you find yourself in this situation. The key is to prevent getting to this point as much as possible.