My Claim Has Been Denied by My Insurer – What Should I Do Now?

If you are told that the claim you made through a prior authorization process for a specialty drug has not been approved, you will receive written notice from your insurer. Your physician or the individual or group that helped you prepare and submit your claim may not have been notified, so be sure to contact them and let them know. Once you have told them your prior authorization claim has been denied, your physician’s office may discuss alternative medication or appeal options. Your patient support program (PSP) or drug access navigator (DAN) may also be able to suggest appeal options with you.

Find out why your claim was denied

When you receive notification that your prior authorization claim has been denied, make sure you have been told the reason why and given a written explanation. If you do not have this information, ask specifically for it from the insurance provider.

If you are not sure why your claim was denied, then you can contact your insurer or the organization who sent you the denial letter to find out the reason for the denial. When you contact them, you will need to know your group policy number and your certificate or member number. You will also need to know the medication you were prescribed and the disease/condition.

Prior authorization drug eligibility criteria can change between insurers, therefore reasons for denying reimbursement for a prior authorization drug can vary. It is important for you to contact your insurer directly because they may not share the reason for denying your claim with your PSP, DAN or your physician. If you are not comfortable talking directly to your insurer, you can ask for a call with your insurer and your PSP or DAN.

Some reasons why your prior authorization claim may have been denied

Your claim may have been denied for one of several reasons. It may be worthwhile resubmitting the claim in the following circumstances:

Additional medical information is required – Information that the insurer would like to see about your medication condition may have been missing or they would like more information about your medical history, your current medical condition, or previous treatments. It is possible your claim will be reconsidered if they have this information.
The drug you have been prescribed is not in the insurer’s list of eligible drugs – In this case, your physician may consider prescribing an alternative drug and you can submit a new claim. If your physician does not want to change the prescription, there may be other sources of funding for your physician’s preferred drug that your DAN or PSP can help with.
The drug has been prescribed ‘off label’ – This means that the drug is not approved by Health Canada for your condition or the stage/severity of your disease. Some insurers will consider ‘off label’ prescribing with additional medical evidence, such as peer reviewed scientific research or clinical trial results. Your physician, PSP or DAN can help you resubmit your claim with additional information that supports the physician’s reason for prescribing the drug to you for your specific circumstances.

If the drug is rejected on appeal

If you have appealed the insurer’s decision to deny your prior authorization drug claim(s), and it is again denied, you have other options. Speak with your physician, PSP, or DAN about their experience with claiming through a pharmaceutical manufacturer’s PSP or a provincial special access drug program. You or the plan member can search one of the following websites:

Drug Access Canada – Provides information and links to alternative reimbursement means for unfunded drug costs, federal and provincial drug programs, and patient support programs for financial assistance in funding prescribed drugs, prior authorization forms for private insurers, and more.
Is My Prescription Covered? is a free and interactive drug coverage finder from the Canadian Skin Patient Alliance. Find out whether the medication you have been prescribed is covered publicly and learn more about private drug coverage.
You can find a list of some of the groups that help patients in the Resources page of this site. Many are knowledgeable on about the drugs and treatments related to their specific disease area. They may be able to refer you to programs or services that may help cover drug costs or access treatment.

Unfortunately, not all medications prescribed will be reimbursed by group benefit plans, public drug programs, or available with financial assistance by patient assistance programs. If you and those assisting you have exhausted all your coverage options, speak with your physician about whether the drug prescribed is within your budget and what other drug options are available for your condition.

Patient or Patient Group