Here’s a scenario I often see as a clinical nurse on the Dermatology Service: A patient who received a stem cell transplant suffers from chronic graft-versus-host disease, in which the cells he received from a donor attack those of his own body. His dermatologist recommends that he use a prescription-strength topical steroid spray to treat his symptoms, so he drops the written prescription off at his pharmacy, intending to pick it up the next day. When he returns, he discovers that the cream has been denied by his insurance company and will cost him $600. The patient purchases the medicine at full cost, unaware of his other coverage options.
Unfortunately, this issue is all too common. Insurance requirements — not to mention the options of brand-name versus generic medicines and other details — can be complex and overwhelming. These tips can help you make sense of the prescription process before your next trip to the pharmacy.
Check with your insurance first.
Insurance companies may publish a formulary (a list of drugs they cover) or a preferred drug list, which provides alternative options for medications that are not covered and parameters for coverage or prior authorizations (PAs). You can ask that these lists be mailed to you, or you can find this information on the insurance company’s website. Some insurers also have a tool for estimating the cost of prescriptions. If you need help understanding this information, you can ask your doctor or nurse, or the pharmacist.Back to top
Ask questions at the pharmacy.
Before you leave the pharmacy, always ask if the prescription you’ve been prescribed is in stock and if it’s covered by your insurance. If it’s not in stock, ask if it can be ordered and how long the delivery will take. If the prescribed drug is denied insurance coverage, ask the pharmacist why and what the next steps are.Back to top
If you’ve been prescribed a name-brand drug, you may ask a pharmacist for a generic product that’s similar and that’s covered by insurance. The same medication may also be available in a different form (for example, a lotion instead of a cream) that would be covered by your insurer. In some cases, an over-the-counter option may also be available at your pharmacist’s recommendation.Back to top
Prepare for preauthorization.
Insurance companies may require a PA before agreeing to pay for a prescribed drug — a process by which the insurer requests more clinical information regarding why you need the drug. To get those details, the pharmacist should contact your clinician’s office, which will then initiate contact with your insurance company and send the information directly. Urgent requests are usually processed within 24 hours and other requests take between 24 and 72 hours. Generally, your doctor’s office must respond within ten days or the PA may be automatically denied.
If the PA is approved, you can fill the prescription. Typically, refills are covered for a year. After a year, the insurance company may require another PA approval.Back to top
If your PA is denied, the insurance company should inform your doctor or nurse. At that point, you may appeal the insurer’s decision. Your clinician will need to provide supplemental information including something called a letter of medical necessity, which will state why it’s vital you receive a specific drug. Urgent requests are processed in one to two days and other requests may take up to a week. If approved, you can get your prescription. If denied, you and your clinician can discuss if the medication is affordable for you to purchase or if there’s an alternate therapy that could be effective and less expensive. It’s also a good idea to ask your clinician to provide a letter of medical necessity up front for drugs that have required PA in the past.Back to top
Be as prepared as possible.
Track the effectiveness of all the treatments you’ve taken — what worked, what didn’t work, and what made the condition worse — including all your prescription medications, over-the-counter medications, and home remedies. This information helps with the PA process. Also, bring a list of drug allergies and medications to your appointments and the pharmacy, and keep the labels with the instructions on how often to take medications or how to apply them.Back to top
Unless it’s critical that you start on the prescribed drug immediately, look into alternative cheaper options. There are a variety of payment assistance programs available from both the government and private healthcare organizations, including the following:
- Medicare’s Help Paying Costs
- Prescription Assistance program
- American Cancer Society Prescription Drug Assistance Program
- CancerCare Co-Pay