Insurance won't pay prescription

[stacylyn]

What is the name of your state? CT

My father is fighting his health insurance company to pay for a prescription that should be covered under his policy. He signed on with this new insurance just this year and checked to make sure that his prescriptions were indeed covered. There was no "pre-authorization" required. When he went to fill the rx, he was told it was denied. He contacted his insurance and they made him send in an appeal, which he did. Again, denied. When he contacted the insurance company again, he was connected to a nurse who reviewed his case. She said that he would be required to try a different type of pain killer before they would consider paying his existing rx. He complyed. This "new" drug didn't work and his symptoms returned. (He suffers from Fibroidmyalgia and a back injury). His doctor ordered him to return on the medication HE prescribed for his condition, NOT what the insurance company recommended he be on. Can you believe that they did this? His family doctor of over 20 years said that in all of the years he has practiced medicine, he has never seen a case like this. The doctor called the insurance company as requested and submitted his medical history from the past 5 years. Again, denied! When asked numerous times why the claim is being denied, the nurse will not give the reason. My father suggested that he would get a lawyer since he doesn' t know what else to do and the nurse replied "you do what you have to do" and left it at that. The State of CT insurance commissioner has been contacted, but we are still waiting to hear back from them. In the meanwhile, my father has had to pay over $300 for his medication in order to lead a decent life without pain. His condition worsens dramactically under stress and this has caused alot of it! He has been forced to miss work and can't get out of bed some mornings. Please advise.

[moburkes]

Originally Posted by stacylyn

What is the name of your state? CT

My father is fighting his health insurance company to pay for a prescription that should be covered under his policy. He signed on with this new insurance just this year and checked to make sure that his prescriptions were indeed covered. There was no "pre-authorization" required. When he went to fill the rx, he was told it was denied. He contacted his insurance and they made him send in an appeal, which he did. Again, denied. When he contacted the insurance company again, he was connected to a nurse who reviewed his case. She said that he would be required to try a different type of pain killer before they would consider paying his existing rx. He complyed. This "new" drug didn't work and his symptoms returned. (He suffers from Fibroidmyalgia and a back injury). His doctor ordered him to return on the medication HE prescribed for his condition, NOT what the insurance company recommended he be on. Can you believe that they did this? His family doctor of over 20 years said that in all of the years he has practiced medicine, he has never seen a case like this. The doctor called the insurance company as requested and submitted his medical history from the past 5 years. Again, denied! When asked numerous times why the claim is being denied, the nurse will not give the reason. My father suggested that he would get a lawyer since he doesn' t know what else to do and the nurse replied "you do what you have to do" and left it at that. The State of CT insurance commissioner has been contacted, but we are still waiting to hear back from them. In the meanwhile, my father has had to pay over $300 for his medication in order to lead a decent life without pain. His condition worsens dramactically under stress and this has caused alot of it! He has been forced to miss work and can't get out of bed some mornings. Please advise.

The insurance company is not required by any law to pay for the prescription that the doctor recommends.

[ecmst12]

If his plan is such that non-formulary drugs are not covered no matter what, and this drug is not in the formulary, then there is nothing his doctor can submit that will get it covered. It's simply a non-covered item. It is unusual that they would not just tell him that though. He needs to read his plan booklet and find out what his prescription coverage specifically says.

[Ozark_Sophist]

Is this a Part D prescription drug plan? How did your father verify the drug was in the plan formulary?

[lealea1005]

Originally Posted by stacylyn

What is the name of your state? CT

My father is fighting his health insurance company to pay for a prescription that should be covered under his policy. He signed on with this new insurance just this year and checked to make sure that his prescriptions were indeed covered. There was no "pre-authorization" required. When he went to fill the rx, he was told it was denied. He contacted his insurance and they made him send in an appeal, which he did. Again, denied. When he contacted the insurance company again, he was connected to a nurse who reviewed his case. She said that he would be required to try a different type of pain killer before they would consider paying his existing rx. He complyed. This "new" drug didn't work and his symptoms returned. (He suffers from Fibroidmyalgia and a back injury). His doctor ordered him to return on the medication HE prescribed for his condition, NOT what the insurance company recommended he be on. Can you believe that they did this? His family doctor of over 20 years said that in all of the years he has practiced medicine, he has never seen a case like this. The doctor called the insurance company as requested and submitted his medical history from the past 5 years. Again, denied! When asked numerous times why the claim is being denied, the nurse will not give the reason. My father suggested that he would get a lawyer since he doesn' t know what else to do and the nurse replied "you do what you have to do" and left it at that. The State of CT insurance commissioner has been contacted, but we are still waiting to hear back from them. In the meanwhile, my father has had to pay over $300 for his medication in order to lead a decent life without pain. His condition worsens dramactically under stress and this has caused alot of it! He has been forced to miss work and can't get out of bed some mornings. Please advise.

If they require him to try a different medication before they'll consider paying, then it may still be on formulary but at a higher tier.

Many people who have been on the same medication for years go through this when changing insurance plans. It frustrating for both the patient and the Physician ordering the medication.

His Doctor will have to document that your father has taken the alternative medication for what ever time his insurance company specifies,and that his condition has worsened while on that medicaiton. Then the Doctor will have to send that documentation to the insurance company. I suggest a fax to the specific nurse manager your father spoke with....they should have a record of his telephone call on file.

It still does not guarantee your father's medication will be approved, but you will have then followed all the necessary steps for an appeal, and possible reimbursement of their "allowable" charge for the medication.

Bottom line, they will tell you that they are not saying you cannot take the medication your Physician is prescribing, just that they will not pay for the medication.

Good luck to you! Please let us know how it turns out.