Insurance Appeals

Your health insurance company might not pay for all prescription drugs or medical services. If it doesn’t, you can appeal. Providers use various names for appeals, such as Request for Reconsideration, Medical Benefit Appeal, Coverage Appeal, Pharmacy Benefit Appeal and Prescription Drug Coverage Appeal.

Why won’t my insurance pay for my drug or service?

Reasons your insurance company won’t pay include:

Your drug isn’t on its list.

Lower-cost drugs are available.

The company hasn’t decided whether to pay for a new drug or treatment.

Your illness doesn’t match what the insurance company has on record.

You’re prescribed a different amount or dosage than what your insurance company allows.

You’re prescribed a certain time to take a drug that your company doesn’t allow.

No matter the reason, you can appeal to your insurance company. To increase your chance of success, follow these do’s and don’ts:

Do:

• Call the telephone number on the back of your insurance card to find out how to appeal.
• Appeal as soon as possible.
• Appeals have a time limit, and they take time to process.
• Ask your doctor to help you appeal.
• Follow the steps your insurance company requires.
• Think about asking someone to help you with the appeal.
• Make copies of your paperwork before you send your appeal.
• Include your name, address and phone number in your appeal.
• Include your doctor’s name, address and phone number in your appeal.
• Include your insurance ID number and any other claim number on everything you send with your appeal.
• Include the name of the drug or service you’re appealing. Include copies of your treatment records from your doctor. Include a copy of representative authorizations.
• Include other items you think support your case.
• Be as detailed as possible.
• Call your doctor and pharmacy after a few days to make sure they’re working on your appeal.

Don’t:

• Wait too long to appeal.
• All appeals have a time limit.
• Think you have to do this by yourself. Most doctors will assist you.
•  Send paperwork that’s not related to your appeal.
•  Resend paperwork unless your insurance company asks for it again.
•  Send your original paperwork, unless you’re told to do so.
• Hesitate to call your insurance company to ask questions.

Medicaid Appeals

Each state’s Medicaid program provides different services. Visit Medicaid.gov and click on your state to see what drugs are covered.

If your drug isn’t on the list, it’s unlikely an appeal will be approved since so many drugs are covered. But your doctor can appeal.
For the appeal process:

• Call your doctor.

• If you’re at the pharmacy, they’ll need to call your doctor. Remember that each state has its own appeals process.

• Check the Medicaid website and click on your state to learn more. Medicaid.gov.

TriCare Appeals 

TRICARE, formerly Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), provides inpatient and outpatient care for current and retired military personnel and their dependents, and some members of the Reserve.

If TRICARE denies your drug or service, you can appeal.

You have up to 90 days from the date of the TRICARE Claim Decision document to submit a Request for Reconsideration. Be sure to include a:

• Signed document with your name, address and phone number

• Reason(s) you don’t agree

• Name of the drug or service you want covered

• Copy of the Claim Decision

• Copy of the Appointment of Representative form (if you have an appointed representative)

• Medical record or other important information

Mail to: Express Scripts, Inc. P.O. Box 60903 Phoenix, AZ 85082-0903

For more information, go to TricareMil or call Express Scripts, Inc. at 1-877-363-1303 (in the United States) or 1-866-275-4732 (outside the United States where toll-free service is established).