Hossam Maksoud, PharmD

More than one-third of adults reported that their health insurance plan would not cover a drug prescribed by their physician over the past year, according to an NPR poll.

 Upon learning of an insurance company’s denial of coverage for a medication, the patient may become stressed and may also be surprised by this occurrence, leading them to potentially take out their anger on the pharmacist or pharmacy staff they are speaking to.

In this situation, the first step a pharmacist should take is to address the customer’s expectations, which may be based on a lack of information. Many patients may expect that they will receive the drug their doctor prescribes without any complications, and that their insurance will cover the cost of the drug with no obstacles. But more often than not, that isn’t how it works at all.

It is important to educate patients that insurance companies typically have formulary drugs, both generic and brand-name. Within their formulary, insurance companies will have both preferred and non-preferred lists, which will have different co-payment requirements. Once the patient understands this, it is possible to work with them and the physician to assess the best way to proceed.

If there is an alternative drug within the same therapeutic class that would be covered by the customer’s insurance, it is possible to call the physician to suggest it. In many cases, the doctor may decide to try the alternative drug.

However, there may be cases in which the physician may say the patient needs the uncovered drug—perhaps the formulary alternative drug was previously prescribed and did not produce the desired result. Whatever the conversation and decision by the physician may be, the pharmacist is the one who will need to be able to communicate this information to the patient because it is crucial to keep the patient in the loop regarding their health care protocol and requirements.

Additionally, it may be beneficial to work alongside the physician’s office to initiate the prior authorization process to impress upon the insurance company that the drug in question is medically necessary. For pharmacists, making sure the prior authorization process keeps moving along is important as well.

As pharmacists know, prior authorization is not a simple process and it is not uniform across insurance companies. Some companies require more documentation than others and it is a pharmacist’s job to invest in staff who will spend the time to follow up with the insurance company.

This task it vital to find out what else is required and whether there is anything outstanding to coordinate with the physician’s office and ensure the missing documents are submitted in a timely manner. If the prior authorization process is completed and the drug is still denied, it may be necessary to discuss with the physician and the patient whether they want to go through the appeal process.

Naturally, prior authorization takes time—usually several days, at least—and during this time the patient will not be able to take their prescribed medication. As a pharmacist, it may be necessary to opt to let the patient pay out of pocket for 2- or 3-days’ worth of medication while waiting for the decision.

In many instances, this option may not be feasible, such as with inhalation, topical, or ophthalmic drugs or injectables. Some pharmacies may also dispense a couple days’ worth of medication at no charge until the prior authorization is granted, but they run the risk of incurring costs if they get a denial. 

This is a risk that some pharmacies are willing to take to ensure their patients are happy and healthy. However, it also can be possible to approach this situation by convincing the insurance company to authorize an emergency supply of a few days’ worth of drugs while the decision is pending.

Sometimes drugs are covered, but at a high out-of-pocket cost to patients. When patients are on maintenance drugs that cost $75 per month, for example, this is not a sustainable cost for many patients. At Community Care’s specialty pharmacy division, we provide specialty drugs in several categories, including rheumatology, dermatology, osteoarthritis, and hepatitis, and many of these drugs have high out-of-pocket costs.

As a pharmacist, it is important to educate patients about the process for obtaining a specialty drug. Many of these medications have no substitutes or alternatives and almost all have high co-pays.

Customers should not hesitate to let their physician know when drugs are beyond their reach in terms of expenses. With specialty drugs, the prior authorization process requires much more documentation and may take longer to complete. In addition, some of these medications will have limited distribution, whereby the drug can only be dispensed by a few particular pharmacies nationwide.

When it comes to cost or co-pays, there are nonprofit organizations that assist low-income individuals with medication expenses. Many biopharmaceutical companies have been expanding their cost-sharing programs in which they help cover out-of-pocket expenses for patients who cannot afford their medications. In addition, some manufacturers offer free trials, which may be a more affordable option for patients.

Furthermore, patients with high out-of-pocket expenses may also realize significant savings by enrolling in a prescription discount card program. As a pharmacist, it may be beneficial to proactively look for coupons and assistance programs and navigate through them for patients to provide the support they may not be able to get anywhere else.

Since pharmacy is, at its heart, a service business, the required process of communicating and educating customers, working closely with physicians, and navigating relief programs offered by manufacturers and nonprofit organizations may help to provide customers with the solutions they need to address the problems and stress of receiving a denial by their insurance company for drugs they may need to maintain their health.

Hossam Maksoud is CEO and founder of Community Care Rx, a unique long-term-care pharmacy based in Hempstead, NY, that provides comprehensive pharmacy services to various types of organizations.

Neighmond P. When Insurance Won't Cover Drugs, Americans Make 'Tough Choices' About Their Health. NPR.org. January 27, 2020. Accessed July 14, 2021.

Articles

Since pharmacy is a service business, the required process of communicating and educating customers, working closely with physicians, and navigating relief programs can help patients customers address the problems and stress of receiving a denial by their insurance company.