What to do When Your Claim is Denied

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.

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