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