Gaining access to new or unconventional treatments is an ongoing problem for people with any chronic disease. Health insurance companies typically publish a “formulary” that lists the drugs, both generic and brand name, that your plan will cover. Prescription formularies are developed based on efficacy, safety, and cost-effectiveness of the medications. Drugs listed in the formulary are known as “preferred” drugs; those not listed are referred to as “non-preferred” drugs.
When your doctor orders a medication that is not listed in the formulary, the insurance company may overrule your doctor’s orders. This can be frustrating for both your doctor and you. Always remember that you have the right to appeal your insurer’s decision. TMA has advocated for its members who need specialty drugs by supporting patients’ rights legislation and offering guidance on how to navigate this dilemma. Here are some general guidelines for dealing with insurance companies that TMA’s members have found helpful:
- How to appeal an insurance denial
- How to fight your insurance company when coverage is denied
- What to do when your health insurance company denies your claim
- Medicare guidelines for those who have subscribed to a Medicare prescription drug program
- On TMA’s online forums, members share experiences about how they access treatments or services when they are denied by insurance
- Veteran can contact TMA to be connected with one of our knowledgeable veteran members who understand how to navigate this bureaucracy
Appealing to drug manufacturers
Sometimes drug companies whose drugs are routinely turned down by insurance companies offer patient assistance programs. Resources for finding such a program include:
Please let TMA know if you find these sites to be helpful so we can keep these resources current. If all else fails, contact TMA to inquire about other possibilities.