The majority of Americans have health insurance that includes coverage for prescription drugs, but unfortunately that doesn’t ensure that they can afford the specific drugs their doctors prescribe for them. Many Americans report that their insurance plans sometimes don’t cover a drug they need, and nearly half the people whom this happens to say they simply don’t fill the prescription. That’s according to a poll released this month on income inequality from NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health. It happened to Sally Radoci, a retired medical secretary who lives in Baltimore. She’s 78 and on a fixed income, and she suffers from acid reflux. In Sally’s case she needed a certain medication for acid reflux and also for severe allergies to bee stings. While one drug can make her condition uncomfortable and life-changing in terms of eating habits, the other is the difference between a life and death event. Insurance companies should scale the importance of the generic drugs they try to pass on to patients who are paying for insurance coverage with the implications to their life.
Denials can be reversed.
A spokesperson for America’s Health Insurance Plans, the national association of health insurance companies, says denials are often a “simple request for more information from the provider or a recommendation for a different treatment that may be more appropriate and effective for the particular patient.” In other words, a patient does not have to accept a denial as the final word, but they need to continue submitting further support for their request, perhaps a note from the doctor stating that the particular drug prescribed is the best one for their individual situation, and that it will cut down future healthcare costs by keeping a patient from an expensive hospital admission. Denials are time consuming and can be difficult for sick patients to deal with.
If you are denied coverage for a necessary drug for a health issue, appeal directly to the insurer and see if there are any actions to take, or supporting documents to provide for a simple reversal if:
- denied payment for the prescribed medication
- ruled that the medication was not medically necessary, and could be substituted
- question of eligilibility for drug benefit
The new law sets the following timelines for insurance companies to review and decide on an appeal:
- 72 hours for denials of urgent care
- 30 days for denials of nonurgent care you have not yet received
- 60 days for denials of service you have already received
- If your appeal is denied, you are entitled to an explanation from your insurer.
- If your case is urgent and you or a loved one are in danger of becoming increasingly ill without treatment, you can ask to have both the internal review and external review conducted at the same time.
If your request is refused, it’s a good idea to speak with the doctor or hospital treating you. Perhaps they have samples of the specific drug they can provide to you, or they can link you to the pharmaceutical company directly for programs that may solve your problem.
Seek legal counsel.
An attorney may be able to help when insurance denies a specific drug required to keep a patient healthy, especially if it can cause serious implications leading to death. Consult with counsel who can speak with insurance companies, file an appeal, or a formal complaint with the state insurance administration. If wrongful death occurred because of an insurance delay and drug refusal, an attorney may be able to help you.