Appeal a Prescription Drug Related Denial
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The cost of insurance has increased and continues to increase significantly over the years.  One primary reason is the increase in the usage and cost of prescription drugs.  Knowing this, health plans have sought ways to reduce their expenses related to prescription drug benefits.  
  1. A common denial is that the prescription drug is not on the Health Plan's Formulary.  The Formulary is a list of covered drug items on the health plan.  If a drug is not listed, the health plan is stating that the drug is not a covered item. 

  2. Sometimes a drug sought is on the Formulary, but the health plan still denies its usage.  This is because the health plan may be stating that the diagnosis indicated by the medical provider is not one normally considered for the usage of the drug.  This is sometimes called "off-label use."  Unless the FDA has approved the medication for a specific prescribed illness or injury, the health plan may deny the claim stating that the use of the drug for off-label use is considered experimental or investigational. 

  3. A prescription drug may also not be covered for other reasons, such as the pharmacy used is not an in-network pharmacy, the drug is not FDA approved, the drug can be purchased OTR (Over the Counter) and therefore a prescription form of the drug may not be necessary and therefore is not covered, or the drug is considered to be used for cosmetic purposes.

How do you combat a prescription drug denial? The following steps may help.

  1. Review the denial with your policy booklet and verify that their denial is justified. If their reason for denial is unclear, call the customer service unit at the health plan for a more descriptive explanation. Record your conversation and document the name of the individual you spoke with for future reference.

  2. Does your health plan cover prescription drugs and did you abide by the policy and limitations by the plan?

  3. Verify that the prescription drug is a covered benefit under your health plan's formulary.  If not, then you will need your physician's assistance to appeal to the health plan with a letter of medical necessity and all accompanying medical records (pathology reports, operative reports) required by the health plan to justify if the prescription drug is medically necessary. (If the office had not done so, then request that the medical office send a letter reconsidering the denial and attach all the necessary medical documentation).

  4. Health plans denying a prescription drug for cosmetic purposes will also need to be appealed for medical necessity. 

  5. Experimental and/or investigational procedures may be covered if the physician writes a letter of medical necessity and provides two articles from established medical journals specifying the benefits and successes of the proposed treatments. (A medical group in Los Angeles appealed the denial of an off-label use of a medication for AIDS patients and won 50% of its appeals using this method)

Journal of the American Medical Association
The New England Journal of Medicine