Fight your prescription drug insurance denial

Health problems are stressful. If your insurance company denies important claims, that's an additional cause for concern.

Additionally, 18% of insured adults reported having claims denied in 2023. Of those who were denied coverage for certain prescription drugs, nearly half said they simply went without them.

Donna Staat is doing her best to stay active and enjoy her early 60s. But she said knee pain made that difficult.

“It wasn't anything major, but unfortunately I broke my leg right after a surgical repair or an arthroscopy for evaluation,” Staat said.

This led to arthritis. Her doctor requested a medication called Zilretta, but she said her insurance denied the prescription.

She ended up paying for it not once, but twice.

Staat said she and her doctor made several phone calls to her insurance company with no results. She ended up paying $1,500 out of pocket for the second treatment.

Dr. Richard Lehman is an orthopedic surgeon who said he spends an inordinate amount of time fighting insurance companies.

“I think a lot of times the insurance company won't approve a medication, an injection or even more physical therapy,” Lehman said. “And a lot of it is just algorithms, right? You say you've had 12 visits, or the algorithm tells us you don't need any more and we simply won't authorize any more visits. And oftentimes, that's what will happen if you appeal and they understand that this is the process, then they will agree.”

Consumer Reports said if you are refused medication, see if there is a way to change the medication.

Ask your doctor for an exception: If no alternative medication is suitable, your doctor can submit an exception request to your health insurance company and prove the medical necessity of his prescription. You can also try step therapy, which involves trying less expensive options for your condition first. If these options are not effective, your doctor may request that the cost of the original medication be covered.

“The only thing that is clear is that you need to have your doctor as your advocate,” Lehman said. “If your doctor isn’t willing to go the distance, you’re not going to get anywhere.”

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Located in the state of Missouri, one of several states that continues to fund a consumer assistance program that advocates for the consumer, Lehman will handle your appeal.

There are states that no longer have a program. However, that doesn't mean you're out of luck. Each state will point you in the right direction online.

Once you've found the right path, ask your provider for help.

“Unfortunately the squeaky wheel gets the oil. So don't just walk away. “Call your insurance company, express your displeasure and let them know: Hey, this is what my doctor recommended or this is what I need, and be an advocate for yourself in the process,” Lehman said .

As for State, she is now prepared for the next insurance battle and said she won't back down this time.

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