Navigating the rules of medical prescription coverage can be more daunting than understanding the tax code. And while insurance coverage varies from carrier to carrier, there are some general practices that consumers can undertake so that they are not doling out hundreds of dollars at their local pharmacy because they can’t wait to get their medication.
Generics v. brand name drugs
While U.S. physicians are some of the brightest in the world, they can sometimes overlook the logistics of the health care system. A physician writes a new prescription for a brand name drug and sends you on your way, confident that he is giving you the key to relief.
Unfortunately, most patients will learn the hard way that just because they have that little piece of paper with a RX listed on it, there is no guarantee that you insurance will pay. Insurance companies will generally deny coverage for a brand name if a generic is available. Why did the doctor give you a brand name drug? You would think they would know better by now.
Generally speaking, insurance companies will not cover a brand name drug if a generic is available. What can you do about getting your prescription covered? The first step is to ask your physician if a generic is available. If so, generics are the same medication as the brand name drug. Don’t assume that your physician will give you the generic unless you ask.
Take care of business before you leave your physician’s office
Getting in touch your physician can be difficult, if not impossible. You are more likely to get a nurse who will follow up in a day or two. When you are waiting to get a prescription filled, you don’t have time to play phone tag.
If your physician’s office is on the ball, they will offer electronic prescription orders. As long as your local pharmacy has all your insurance information, the physician will send over the scrip electronically and the pharmacy can confirm if the medication, as written, will be covered. If your physician doesn’t have electronic prescriptions, then make sure that you have your insurance companies pharmacy prior authorization number loaded as a contact in your cell phone.
As soon as your doctor writes you a prescription, take out your cell phone and call the prior authorization department. Tell them what the doctor has given you and ask if it is covered. If they tell you it is not, locate the doctor or nurse and tell them of the problem, as the physician’s office will need to either change the prescription or document to the insurance carrier as to why you need that particular drug.
You don’t want to leave the doctor’s office without knowing for sure about coverage for this new prescription. If you wait until you are at the pharmacy, the wait for prior authorization can take days to work through the system.
Other ways the insurance company can deny coverage
Another example of how insurance companies deny coverage is by arguing that other medications must be tried for a certain period of time before they will agree to the other types of medications. Once again, you need to clarify these issues before you leave the physician’s office so that it can be resolved on the spot.
In addition, the insurance company can deny coverage because of the number of doses prescribed. For example, millions of Americans suffer from GERD and have looked to drugs such as Nexium for relief. Typically, insurance will cover one 40mg pill per day. However, if your doctor wants you to take 20mg twice per day, one dose before breakfast and dinner to spread out the stomach acid reducing medicine, the insurance company will deny the coverage.
You may be wondering why in the world would they do that. It is the same amount of medication. It is just packaged in two pills instead of one. How much can that little plastic pill container cost? Even though the cost to the carrier is minimal, they will deny coverage.
What do you do? If you are still in the doctor’s office, as recommended above, you have the doctor tear up the old prescription and write you a new prescription for the 40mg once per day and then when you get home you can split the medication and take it twice per day. If it’s a pill, you can buy a pill breaker and if it is powder or granules (Nexium), you can divide it up and mix the doses with applesauce.
By taking these simple steps you can avoid having to decide between paying hundreds of dollars for medication that should be covered or going without your medication while the prior authorization system inches along.