3 Ways to Appeal Insurance Denials for Prescription Refills
Last updated: February 2022
“Your insurance provider will not cover your prescription refill.”
It’s a phrase nearly every person with chronic pain or a headache disorder fears; maybe it’s a phone call, a pharmacy app notification, or a face-to-face conversation with your pharmacist. No matter how the information is delivered, it strikes you in the gut. Panic rises in your chest. You yell, cry, scream—whatever works to release your frustration.
Not enough medication for the pain
You need this medication to function, to treat your pain. What bureaucrat decided that four pills or four injections a month is enough to treat a condition that plagues you multiple times every day? Why does their opinion trump your doctor’s orders? How can you fight this unjust decision? This issue is so pervasive that some cluster headache patients give their medication to other patients whose insurance won’t cover the cost.
Whether you have migraine disease, cluster headaches, or another painful condition, there are a few ways to appeal a health insurance coverage denial and avoid paying hundreds (thousands even) of dollars out of pocket.
Your doctor can appeal the insurance provider
Your insurance card has a phone number for providers to call to appeal a decision on prescription coverage. Not only is this call line answered faster than the number for patients, but it’s also a streamlined process for physician’s offices to appeal an insurance policy on certain medications or seek pre-approval on a procedure. Ask your doctor to call on your behalf to increase the allotment for your treatment every month.
My primary care physician did this for me several times when I was entirely out of sumatriptan injections. I had already spent $900 out of pocket on them (which got me ten auto-injectors), and he convinced my insurance provider to cover double the usual allotment.
Ask the pharmacist for help
I’ve broken down in sobs at the pharmacy more times than I care to remember. The issue was so common that when I was doing better and no longer needed to go to the pharmacy every day, the pharmacist called to check in on me. Similar to your doctor’s pull with your insurance company, your pharmacist can make a call to get them to cover another refill. It’s not a permanent fix, but it can work once or twice in your favor.
Fill out an appeals form
A patient appeal is your slowest option. It can take weeks for an insurance representative to review your claim and get back to you with the decision. However, it could provide lasting coverage for more refills of your medication each month. Most, if not all, providers have an online appeal form for you to fill out, but they may want you to fax or mail them one. I’ve tried this a handful of times with sumatriptan injections or oxygen coverage and been denied every time. However, you could have more luck than I did.
Do you have advice for navigating health insurance denials for prescriptions? I’d love to hear about your experience in the comments!
Have others downplayed your migraine pain?