You and your doctor have decided which treatment is the right one for your eczema. But your health insurance company either won’t cover (pay for) your prescription at all or is requiring you to jump through certain hoops before they will cover the medication. What do you do?
Health insurance companies put in place policies intended to help control their costs. These policies sometimes are in direct conflict with what doctors decide is best for patients and their particular medical needs. The following are some common ways health insurers deny patients access to treatments and care and what you can do about it.
Prior authorization requires your doctor’s office to submit a form detailing your medical history, current health issues, medications, and other relevant clinical information, for review by your insurer before submitting a prescription. Based on the information provided in the prior authorization form, your insurer with either 1. Approve the treatment; 2. Deny the treatment; or, 3. Request more information.
Insurance companies are increasingly relying on prior authorization to control prescription drug costs, especially if it is a brand-name or “specialty” medication (no generic alternative). For both patients and doctors, prior authorization is a time-consuming, costly and resource-intensive process that can delay treatment. Treatment may be further delayed if the insurer denies the medication or requests more information before making a decision.
What you can do about prior authorization
If your insurance company denies your treatment you have a right to appeal your claim. There are two ways to file a health insurance appeal. One is through an internal appeal that asks the insurance company to conduct a full and fair review of its decision. You must file your internal appeal within six months of receiving notice that your claim was denied. The Patient Advocate Foundation offers templates for writing effective appeal letters.
Your health insurer is required to respond to your appeal:
Within 15 days if you are seeking prior authorization for a treatment
Within 30 days if you are appealing a denial of coverage for a medical procedure you have already received
Within 72 hours for urgent care cases
If the internal appeal is denied, you can file for an external review. This calls upon an independent third party to review the insurer’s decision, which means the insurance company no longer gets the final say over whether to pay a claim. In urgent situations, you can request an external review even if you haven’t completed all of the insurer’s internal appeals processes.
Also known as “fail first,” step therapy requires a patient to try and fail another (usually less expensive) drug before the insurer will cover the medication originally prescribed by the doctor.
Step therapy can be bad for patient health if the “step” drug the insurer requires:
Is contraindicated (should not be used) because of the patient’s medical history or current health status
Delays appropriate treatment so the patient’s symptoms worsen or health deteriorates
Is expected to cause significant side effects due to the patient’s gender, biology and severity of disease
What you can do about step therapy
If you and your doctor decide that it’s better to avoid step therapy and go straight to the treatment prescribed, you will need to get prior authorization from your insurance company before they will cover the cost.
Your health plan has a list of certain prescription drugs that they will cover if prescribed by your doctor. This list is called a formulary. However, just because a drug is on a formulary, doesn’t mean that the full cost will be covered by the insurer. Drugs are tiered from 1 to 4 within the formulary, and the higher the tier, the more money you will pay to get your prescription. If you are unsure where your treatment falls on the formulary, check the website of your health insurer.
Most generic drugs such as generic topical steroids are on Tier 1 and have the lowest co-payment amount. Tier 2 drugs are brand-name drugs such as Elidel and Protopic that are “preferred” by the insurance company because they are less expensive. Patients pay a higher co-pay amount for these medications than they do for Tier 1 drugs. Tier 3 drugs are brand-name drugs that are “non-preferred” by the insurer and cost patients even more in copays than the previous two tiers. Tier 4 drugs are typically specialty drugs, for which there is no lower cost or generic equivalent, biologic drugs such as Dupixent are often in this category. Patients accessing Tier 4 treatment either pay the highest co-pay of all the tiers or pay what is called “co-insurance,” which is a percentage of the cost of the drug. Co-insurance can require patients to pay up to 40% of the insurer’s cost to purchase the drug, which can make these life-saving medications unaffordable for many Americans.
What you can do about drug tiering and high out-of-pocket costs
Start by taking a look at our financial aid resources for prescription medications to see if you qualify for one of the programs listed. If you are on a name-brand medication, pay special attention the section on drug maker patient assistance programs. If you don’t see your treatment listed, ask your doctor about any payment assistance programs or call the company that manufactures your medication.
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