23 msfocusmagazine.org Drug Administration on the basis of their close similarity to the branded one. However, they may not be identical. What are some of the reasons insurers give for denying coverage for a prescribed medication? • You did not receive the required pre- authorization foryour prescribed drug (your prescriber may need to first show the drug is medically necessary). • You did not complete the required step therapy (you must try one or more similar, lower cost drugs before the plan will cover the prescribed drug). • The prescribed drug is considered experi- mental or investigational. • Your drug is not recognized by the FDA to treat your condition. • You may have exceeded the plan’s quantity limits for that medication. How do I know why my insurer wouldn’t cover my prescribed drug? You’ll learn why from your insurer in an Explanation of Benefits or a denial letter you receive in the mail. It should also tell you how to appeal the decision and give timelines. If you get answersverballyfromyourpharmacist or by calling your provider, make sure you get the denial in writing, too. What can I do to get my health insurance provider (a private company) to cover the drug that was denied? First, follow your insurance company’s formulary exceptions process. Usually, your doctor must confirm to your health insurer that the drug is appropriate for your medical conditionbasedononeormoreofthefollowing: • All other drugs covered by the plan haven’t been or won’t be as effective as the drug you’re asking for. • Any alternative drug covered by your plan has caused or is likely to cause side-effects that may be harmful to you. If there’s a limit on the number of doses allowed, your doctor must provide evidence the allowed dosage hasn’t worked for your condition, or show why the drug likely won’t work foryou based on your physical or mental makeup. In addition to your medical history relevant to the case, include peer-reviewed articles from your doctor’s professional journals or magazines that support the treatment your doctor recommends. Also, your plan’s Evidence of Coverage contains detailed guidelines that explain what the company considers medically necessary. Use these guidelines to help explain why a particular drug is a medical necessity for you. My insurer denied my request for an exception. Now what do I do? If your plan offers no more internal reviews, file for an external review with your state’s insurance regulator. Ifyour state doesn’t haveanexternalreviewsystem,theDepartment of Health and Human Services or an independent review organization will over- see the process. A final decision can take up to 60 days and is free if handled by HHS, but may cost a small fee if it’s handled by your state or an independent review organization. The information on your EOB or on the final denial of the internal appeal by your health plan gives you contact information for the organization that will handle your external review.