Last updated: Jan 10, 2011
money-hand-holding-pills
Enlist your doctor to help you get coverage for drugs your insurer doesn't want to pay for.
(ISTOCKPHOTO)
Sometimes a drug you really need or want is not covered by your insurance plan. Insurers keep a list of drugs, called a formulary, that they have approved for reimbursement. The formulary is updated several times a year, and although improving health care is one criterion for what is included or excluded, so is cost. That can mean that new or more expensive drugs are covered less—or not at all. Or a drug may be approved by the insurer to treat one condition but not another. For instance, one woman suffering from excruciating back pain found that her insurance company wouldnt cover the painkiller her doctor prescribed because it was only specified for breast cancer patients. She ended up on an alternative medicine, but she and her doctor felt it was not nearly as effective. It can be a lot of work, but in some cases it may be worth trying to change your insurer's mind. Here, Nancy Davenport-Ennis, CEO and president of the Patient Advocate Foundation, and Joseph Augustine, a litigator in private practice in New York, explain how to turn a denied claim into a covered benefit.


Q: What documentation do I need?

A: "You should take copious notes of all phone calls and demand a detailed written explanation for the denial—not just a one-sentence letter, but one that sets forth the exact policy language the insurer based its decision on," advises Augustine. "In your appeal, youll want to address the insurers stated reason for the denial and why you think it was wrong."


Q: Is there anyone who can help me?

A: Your doctor will be able to help you—and may be able to handle the appeal for you, says Davenport-Ennis. Also, if you're insured through your employer, call the benefits manager and explain the problem. She can answer questions about the policy and, in some situations, put enough pressure on the insurance company to get the denial overturned. (For more tips, check out PatientAdvocate.org or contact the Patient Advocate Foundation at 800-532-5274.)

Q: Do I have to make my appeal within a certain time frame?

A: Most likely; you can find out what that time frame is by calling your insurer or reading your policy. Do not delay in filing the appeal, says Augustine. "Failing to make a deadline can sometimes limit or cut off your rights," he notes.

Q: What information should I include in my appeal letter?

A: An appeal letter should include your policy number, group number, claim number, the reason for the denial (which should have been specified in the denial letter), as well as a brief history of the illness and why this drug is the best treatment, says Davenport-Ennis. Also state why the denial decision was wrong. For instance, maybe you have side effects with the preferred drug or your condition is so serious that, in the opinion of your doctor, it requires the most potent drug.

"The key is to be concise and to the point, and to advise the insurer that you are prepared to appeal any denial to the last step," says Augustine.

Q: What else should I include along with the appeal letter?

A: Davenport-Ennis advises that you include:

  • A letter from your doctor that explains your specific case and why the drug is medically necessary.
  • Studies from professional medical journals proving that the drug is helpful for your condition. Your physician can assist you in obtaining these articles.
  • Statistics on whether your insurer has reimbursed patients in the past for the same medication. "Ask your doctor if she knows of any cases," says Augustine. "You can also ask your insurer if it has approved such medications in the past, and demand a numerical summary of all claims made for the same prescription and the number of times the insurer granted or refused reimbursement for it. If they have granted it for others, they will have to explain their criteria and why they denied it to you."
  • Finally, make a copy of all the information and send it via registered mail.


Q: If my appeal is turned down, do I have any recourse?

A: You can reappeal (one or two times, depending on your plan's rules), notes Davenport-Ennis. You'll need to prepare a new appeal, in which you'll want to include new information that specifically addresses the reasons cited in the denial. Again, keep copies of all information and send the packet via registered mail.

If you get a final denial, the next step may be a free external review by a third-party company, which will reconsider your insurers decision. For details about your state's external review program, check out the Consumers Unions Consumer Guide to Handling Disputes With Your Employer or Private Health Plan.