Enlist your doctor to help you get coverage for drugs your insurer doesn't want to pay for.
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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 wouldn’t 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, you’ll want to address the insurer’s stated reason for the denial and why you think it was wrong."
