When a Claim Has Been Denied

If the plan member is advised that the claim made through a prior authorization process for a specialty drug has not been approved, they will receive written notice from their insurer. The prescribing physician or the individual or group that helped prepare and submit their claim may not have been notified, so remind the plan member to contact them and let them know. Once they have been informed, the prescribing physician may discuss alternative medication or appeal options. The patient support program (PSP) or drug access navigator (DAN) may also be able to suggest appeal options.

Find out why the claim was denied

When a plan member receives notification from their insurer that their prior authorization claim has been denied, make sure they understand the reason why and make sure they ask for a written explanation.

If the plan member is not sure why their claim was declined, then they can contact the insurer or the organization reviewing the claim to find out. They will need to know their insurer, group policy number and their certificate or member number before they call. They will also need to know the medication they were prescribed.

Prior authorization drug eligibility criteria can change between insurers, therefore reasons for declining reimbursement for a prior authorization drug can vary. It is important for the plan member to contact the insurer directly because they may not share the reason for declining the claim with their claims advocate or their physician.

If the plan member is not comfortable talking directly to their insurer you can join the call or the plan member can ask the PSP or DAN to join the call.

Some reasons why the prior authorization claim may have been denied

A prior authorization 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 the plan member’s medication condition may have been missing or they would like more information about the member’s medical history, current medical condition, or previous treatments. It is possible the claim will be reconsidered if they are sent more information.

The drug prescribed is not in the insurer’s list of eligible drugs – in this case the physician may consider prescribing an alternative drug and the plan member can submit a new claim. If the physician does not want to change the prescription, there may be other sources of funding for the physician’s preferred drug that the drug advocate can help with.

The drug has been prescribed ‘off label’ – this means that the drug is not approved by Health Canada for the plan member’s disease or the stage/severity of the disease. Some insurers will consider ‘off label’ prescribing with additional medical evidence including peer reviewed scientific research or clinical trial results. The physician or claims advocate can help resubmit the claim with additional information that supports the physician’s reason for prescribing the drug ‘off label’.

If the drug is rejected on appeal

If the insurer’s decision has already been appealed and it has been rejected, then there are other options. The plan member can speak with their prescribing physician, PSP, or DAN about their experience with claiming through a pharmaceutical manufacturer’s patient support program 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 prescriber 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 prescribed is covered publicly or privately.
Disease/Patient Group for the plan member’s diagnosis. You can find a list of some of these groups in the Resources page of this site. Many are knowledgeable on the drugs and treatments related to their specific disease. They may be able to refer the plan member 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 the plan member and their advocates have exhausted all coverage options for the drug(s) the physician has prescribed, the plan member should speak with their physician about whether the drug prescribed is within their personal budget and what other drug options are available for their condition.

Plan Sponsor or Advisor