Please note our 2023 holiday schedule will be as follows. Our office will be closed Monday, December 25, 2023 through Monday, January 1, 2024 and will reopen on Tuesday, January 2, 2024, at 8:30 am EST.✕
Patient Advocate Foundation (PAF) is a national 501 (c)(3) non-profit organization which provides case management services and financial aid to Americans with chronic, life threatening and debilitating illnesses.
If a pharmacist tells you your claim has been denied by your insurance, you have a few options available to you. Below are some tips to help guide you.
Find out why your claim was denied
It is important to know why your claim was denied. Were you denied because the drug is simply not covered by your health insurance plan? Or were you denied because of a restriction that prevents you from having the prescription filled?
Know the restrictions
There are three restrictions that could result in your claim being denied.
Step therapy: You are required to try a cheaper drug before you are approved for the more expensive version.
Prior authorization: You need your doctor to obtain permission for the drug before your plan will cover it.
Quantity limits: Your drug has a limit to the amount you can be prescribed over a certain time period. If you have gone over this limit, your doctor will need to obtain authorization from your insurance provider before your prescription will be filled.
Ask your doctor to request an exception based on medical necessity
Your doctor can request that your plan cover the medication by exception if they feel that another medication that is covered by the plan will not work effectively.
Ask your doctor for a different medication that is covered by your plan
Make sure to discuss the risks and benefits with your doctor before making a decision.