Disclosure: The author’s opinions are her own and do not reflect policies or opinions of, nor does she speak for, any insurance company or benefit manager.
You’ve heard the terms.
Sometimes, the medicine your doctor says you need (or that you have been taking) seems like it’s on lockdown by your insurance.
Want to give yourself the best chance for getting your medicine approved?
Let’s have a look:
1) You should have one of the health conditions for which the drug has been approved. Sometimes there are approvals for what are known as “off-label” (not approved by the FDA for that use) uses. Many times there are not.
2) If you receive a letter of denial due to not having an approved health condition (but you know for sure that you have been diagnosed with this health condition), make sure to follow up with your doctor’s office.
- Many times the Dr’s office puts diagnosis codes on the PA request, but none of them are the right codes.
- If the PA reviewers cannot get hold of your doctor’s office to clarify, there is no way to approve it for you.
- The reviewers usually must get the information about the health condition that the drug is being used for from a health care professional at your prescriber’s office, and you won’t be able to provide that information yourself, nor can you have your friendly neighborhood pharmacist (or a friend who is a doctor, but not yours) call that in for you to speed things along.
3) All insurance companies (including Medicare Part D) have required timeframes for when your PA request must be finalized and a decision made.
- If the information is not given to the reviewing pharmacist or technician and they cannot get the information needed before the time is up, you will receive a denial letter and have to try again on appeal.
- When at all possible, DON’T REQUEST AN EXPEDITED REVIEW unless your doctor knows the information needed and gives it all on the first fax or call.
It is in YOUR best interest to give the reviewer for your case AS MUCH TIME AS POSSIBLE.
Many times, the doctor’s office is hard to get hold of. They’re busy people!
- The person reviewing your case calls – gets a receptionist, who leaves a message or transfers them to a voicemail, or the designated person in the doctor’s office who handles PAs isn’t in or is gone for the day. Or the doctor is already gone.
- The reviewing pharmacist THEN faxes for the missing info. The fax could get lost, or buried under lots of other faxes coming into the doctor’s office, etc. You get the idea. OR, they don’t have a fax number or have the correct fax number.
Don’t panic! Calls and fax attempts are usually made daily.
If the doctor’s office staff cannot get the answer, OR cannot get back quickly to the reviewer of your request, the request must be denied, when there is no way to approve it with the original information given. The time to make a decision on your case is coming to a close.
So if you (or your doctor’s office) asks for EXPEDITED – this does not help you when the reviewers cannot get hold of anyone for the answers they need.
4) Ask the Dr’s office if they send in the chart notes for your most recent visit with the PA request.
- The reviewers can look in the Dr’s notes and see if you talked about anything with your doc that wasn’t on the list of original diagnoses.
- If it IS there, you COULD get an approval! More information can definitely help with the review process.
5) Read your denial letter. They should give you a specific reason why it’s been denied.
- Sometimes, you may have a medical condition that makes it not safe for you to take the medicine requested.
- Sometimes, you haven’t tried other medicines they do cover, OR your doctor maybe doesn’t know what you’ve tried and failed in the past. Since they don’t usually ask you that on the *ahem* VERY LONG QUESTIONNAIRE most Dr’s offices make you fill out when you’re a new patient, you’ll probably have to tell them what you’ve previously tried that didn’t work or maybe only worked kind-of-a-little-bit-but-this-one-works-much-better-thank-you-very-much.
- Sometimes, it’s just not covered by Medicare, due to exclusion by Part D Law. There are MANY reasons for exclusion by the law.
- Sometimes, the reviewer can’t get the information needed to make a decision in your favor in the time allotted.
I was denied my medicine when the doctor’s office submitted a Prior Authorization for me. What now?
YOU HAVE THE RIGHT TO APPEAL if you get a denial. Over and over, sometimes.
You can’t always appeal to the same place who previously reviewed your request, but there are appeal levels. Check your denial letter for the correct address to which to send your next appeal.
Just like your first (initial) request for the medicine, the reviewers who do your review for your appeal have set timeframes (determined by the Medicare law, or by your insurance company) in which they must be finished and give you the decision.
The appeal review timeframes usually are longer than the initial request review timeframes.
But again – I caution you – be very careful when you request an expedited appeal. You want to give yourself the most amount of time you can, so they can have the best chance to get hold of the doctor and get any missing information to get an approval if they can. I recommend only asking for expedited if you’re SURE the Dr’s office will be giving all the needed information.
My medicine got approved (woohoo!), but the price is outrageous! I think I might have to take out a loan to pay for it! Is there anything I can do?
If your insurance is Med D, you COULD ask for a tiering exception. However:
- Many pricey medicines are on a Specialty tier, or on a tier where there’s not another level to “tier down” to (meaning get the cheaper price of the drugs on the tier below it – brand name drugs are not allowed to be approved down to a generic tier’s cost).
- These will all get denied, since there is no tiering for Specialty tiers, and no tiering for a brand-only drug if there are only generic tiers below it.
- Non-formulary drugs that get approved? Not eligible by Medicare for any tiering, since they’re not on a tier (they’re not on the formulary, so no way for them to be on a tier).
- Do not yell at the insurance people, or the reviewers, or the dr’s office, or the pharmacy staff. We are all frustrated at the skyrocketing costs of medicines, while our paychecks seem to shrink.
- Don’t throw tomatoes at me – I’m the messenger and keeping it real for you – when you get approval to HAVE the medicine, the price will likely be expensive. Brace yourself, and have a plan ready.
What to do, what to do…
- The best thing is to find your plan documents – check the formulary online.
- See what tier the drug is on, if any.
- Check the tier structure (like in the graphic above) for medicines for your insurance, and see what the tiers are called, or what kind of drugs are in the various tiers.
- See if their website has information on the Tiering process.
If you need help, call your insurance company and they should be able to help you figure this out.
So, friend, you may have to try some more of the plan’s formulary drugs, or get yourself a side-hustle and earn extra dough. Become a YouTuber…start a blog…learn a new skill or hone/uncover a hidden, budding talent.
Dave Ramsey, Clark Howard, Penny Pinchin Mom, or Making Sense of Cents should be able to help you with some money-saving ideas. There are also plenty of inexpensive online courses out there to learn new things online and start freelance work.
Hopefully, this helped give you a peek into the PA process for medicines.
Do you have any other questions? Put them in the comments and I’ll do my best to help you.