Battling your prescription drug insurance denial

Facing health issues is stressful. Being denied by your insurance for crucial claims is added worry.
On top of that, 18% of insured adults reported experiencing denied claims in 2023. Of those denied certain prescription drug coverage, nearly half said they simply go without.
Donna Staat is trying her best to stay active and enjoy her early 60’s. But she said knee pain is making that difficult.
“It wasn’t anything major, but unfortunately, right after I had a surgical repair or just an arthroscopy to kind of investigate it, I broke my leg,” Staat said.
This led to arthritis. Her doctor called for a drug called Zilretta, but she said her insurance denied the prescription.
Ultimately, she ended up paying for it not once, but twice.
Staat said she and her doctor made multiple phone calls to her insurance company with no outcome. Eventually, she ended up paying $1,500 out of pocket for the second treatment.
Dr. Richard Lehman is an orthopedic surgeon who said he spends an exorbitant amount of time battling insurance companies.
“I think a lot of times the insurance company won’t approve a drug or an injection or more physical therapy,” Lehman said. “And a lot of that is just algorithms, right? They say you’ve had 12 visits or the algorithm tells us you don’t need any more and we’re just not going to approve any more. And a lot of times what’ll happen is when you appeal and they understand that this is the process, they’ll agree.”
Consumer Reports said when you’re denied, see if there’s an option to switch drugs.
Ask your provider for an exception: If no alternative medication is suitable, your doctor can submit an exception request to your health plan, showing the medical necessity of their prescription. You can also try step therapy, which is trying lower-cost options for your condition first. If these options aren’t effective, your doctor can request that the original medication be covered.
“The one thing that’s clear is you have to have your doctor as an advocate,” Lehman said. “If your doctor is not going to be willing to go the distance, you’re going to get nowhere.”
Lehman is in the state of Missouri, which is one of several states that continues to fund a Consumer Assistance Program designed to stand for the consumer and will look at your appeal.
There are states that no longer have a program. However, that doesn’t mean you’re out of luck. Each state will point you in the right direction on the internet.
Once you’re pointed in the right direction, ask your provider for help.
“Unfortunately, the squeaky wheel gets the oil. So don’t just walk away. Call your insurance company, voice your displeasure, and let them know, hey, this is what my doctor recommended, or this is what I need, and be an advocate for yourself,” Lehman said.
As for Staat, she is now prepared for the next insurance battle and said this time she will not back down.