Why Your Insurance Won’t Pay For Your Medications

It’s never fun when a healthcare provider prescribes a medication for you and then you find out your insurance won’t pay for the medication.

There are many reasons your insurance company may not pay for your medications. This usually causes a lot of worry, anxiety, and anger since you just had a medication prescribed for you and then come to find out you can’t pick it up at the pharmacy. But why does this happen? Why wouldn’t your insurance pay for your medication?

Well, there can be many reasons, but there’s a common core of why the insurance won’t cover something. And that’s cost.

The goal of an insurance company when it comes to your medication coverage is to make sure you get medications you need at the most effective cost. And that’s understandable, because that’s their business model. They make their profits by controlling costs. So they create a formulary, certain rules and stipulations on how they will manage your prescription benefits. However, it can feel very imposing sometimes since they are interfering with something your prescriber felt you needed and it turned into a really frustrating experience. Although cost is a common reason, your insurance can also reject prescriptions due to safety reasons as well.

Let’s go through the most common reasons why insurance companies refuse to pay for medications.

High Dosage. Some insurance plans will not cover a medication due to the dosage of that particular medication. And this rejection could take place for a couple of reasons. It could be because of the number of times per day you’re taking a medication. For example, some medicines are only meant to be taken one time per day, but if your doctor prescribes it for twice a day, the insurance may not cover it. Or, it could be because of the maximum daily dosage. For example, some insurance plans may limit a medication to no more than 30 mg per day of that particular medication. So if your prescriber wanted you to take 60 mg of that medication, it may cause an insurance rejection.

Duplicate Therapy. Sometimes your insurance will not cover a medication because you’re already taking one very similar to it. The best example of this I can think of is with the non-steroidal anti-inflammatory drug (NSAID) ibuprofen (brand name ADVIL). If you pick up ibuprofen and then try to pick up another NSAID like say, naproxen (brand name Aleve), your insurance company will recognize this as being the same type of treatment and not cover it. This happens because they think its dangerous if you take these two at the same time. Sometimes this can be frustrating because your prescriber could be switching you from one similar medication to another. In the case that you would not be taking them at the same time, usually a phone call to the insurance company can resolve the issue.

Too soon. When your prescription is processed through your insurance company, they know exactly how long that prescription should last. For example, let’s say you picked up your acid reflux medication and it had 30 pills and you are taking it once everyday. In theory, that medication would last you 30 days. Your insurance won’t cover your next refill until you’re out or near finishing that 30 day supply. They usually don’t make you wait until the 30th day, they may give you a few days buffer before they cover it. But, if you tried to fill that script 2 weeks after picking up a 30 day supply, your insurance may not cover it, because it’s too soon.

Over the Counter. If a medication is available over the counter (OTC), some insurance plans will not pay for them. This depends on the plan and sometimes they cover some but not other OTC medications.

There are other cheaper options. Sometimes doctors prescribe newer, more expensive brand name medications. Sometimes it’s for the better, but sometimes it’s because they had a drug rep come in and provide them with coupons and data on why a newer brand named drug should be used versus the cheaper options. But your insurance company usually follows nationally recognized guidelines for treating disease states, and if these guidelines have not accepted that a newer brand name medication is superior to alternatives, your insurance likely won’t cover it. Some drugs that are prescribed for you have cheaper alternatives available that are, usually, just as effective. Rarely they’ll flat out not cover the prescribed medication, but more likely, they’ll want more information from the prescriber through the prior authorization process.

Not So Common Reasons. If you’re going to be filling a prescription every month, like a cholesterol medication, your insurance company may want you to have the medication sent directly to your home through a mail order pharmacy. Or they would prefer you fill a 90 days supply of your medication versus a 30 day supply. Also, if a medication being used to treat a particular medical condition that is not approved by the FDA, your insurance may deny payment of your medication. I’ve also seen insurance companies not pay for medications because a patient has not payed their insurance bill. Lastly, some insurance companies have started adopting the model of using preferred pharmacies, so they’ll only cover your medication if you take them to specific pharmacies.

So your insurance rejected the claim, what are your options?

In the case your insurance company doesn’t pay for your medications, you have 3 options.

1. Pay out of pocket for the medication. Sometimes this can be unreasonable especially if your medication costs hundreds or even thousands of dollars. But, sometimes it could be under $20 if you pay out of pocket. Ask your pharmacist for the cash price.
2. See if there are over the counter options that would work just as well.
3. Have your prescriber complete a prior authorization (PA).

The best option for you should be discussed with your pharmacist after an insurance rejection. PAs can be completed so I’ll go more into that next.

Prior authorization. A PA is a fancy word for your insurance company wanting more information from your prescriber as to why they’re prescribing a specific medication. This will usually happen because of some previously described problems, e.g. high dosage, duplicate therapy, etc. These are required to be completed by your prescriber before they’ll cover a specific medication. Here’s the process:

1. When your pharmacy processes your prescription through your insurance, they’ll get an alert that this medications needs a PA.
2. The pharmacy sends a form to prescribers office which they fill out then send to insurance company.
3. The insurance company will then approve or deny to cover the medication based on the information provided and will provide your prescriber with a decision

You usually won’t find out a PA is needed or can be completed until after the prescription has been taken to the pharmacy and the pharmacy processes the script through your insurance. In the event of a PA denial, your prescriber can appeal that denial for further evaluation.

I’m confident the above covers 98% of reasons why your insurance may not cover your medications. If you think I missed one, send me an email so I can update this. And if the above didn’t help you in your situation, reach out to me so we can try to figure it out.

Thanks for reading,

-Richard

—

Richard Waithe, PharmD | Richard@MedVize.com

It would mean a lot to me if you hit the heart button below to recommend this. ❤

Connect with me: Facebook | Instagram | Twitter | LinkedIn

Visit MedVize.com to see how I’m helping people better manage their health and medications.