22 msfocusmagazine.org Hot Topics “I’m sorry, but your insurance doesn’t cover this prescription. Would you like to pay out-of-pocket?” Those are discouraging words, for sure, but they don’t have to be the final words. As a health plan enrollee, you have the right to follow your plan’s procedures to show why the medication you’re seeking is the most effective one for your condition and should be covered. To start: • Find out if anyone onyourdoctor’s staff helps resolve insurance issues. • Eliminate the possibility of clerical errors or wrong coding as cause of denial. • Ask your doctor to call your insurance company and offer additional information that may satisfy plan requirements for coverage. • Request a peer-to-peer review between your doctor and a doctor representing the insurance company. Whether you’re advocating with your insurance company or someone else is taking the lead, be informed. The following questions and answers describe how private insurance companies and public health insurance programs determine drug coverage as well as their general appeal procedures. Timelines vary, but most plans offer expedited appeals if your prescriber can prove your need is urgent. Thepharmacistsaidthedrugprescribedfor me isn’t on my insurance plan’s formulary. What’s a formulary? Aformulary is a list of drugs your insurance plan approves and prefers for certain medical conditions. Drugs on a formulary are usually grouped into tiers according to cost. If you have a choice of healthcare or prescription plans, you can select one that covers your current medications. However, drugs can be dropped from or added to formularies at any time. What if my plan offers a generic or biosimilar drug instead of the name brand drug prescribed? Whether to accept a generic or biosimilar drug, or appeal to try and get coverage for the brand name drug, is a decision you and your doctor will make after reviewing the options. Biosimilars and generic drugs are more affordable versions of brand name drugs and have been approved by the U.S. Food and Persistence Pays Off When Persistence Pays Off When Pursuing Prescription Appeal Pursuing Prescription Appeals s By Gay Falkowski