Coverage denied? Here's what to do.

| Kathleen Carter

Every day at the Patient Navigation Center, we hear from people who can’t get insurance coverage for their psoriasis or psoriatic arthritis prescription. This can be confusing, frustrating and makes a lot of people want to give up. They may decide to switch treatments or stop treating altogether. 

While fighting an insurance denial may seem daunting, it’s important to know that you have options and that there are resources to help you. To help you take charge during Psoriasis Action Month, here are some tips to stay informed and to keep you and your health care provider in the driver’s seat when it comes to making treatment decisions. 

First, get the details

Your insurance company should be able to provide you with any and all reasons about why your treatment isn’t being covered. There are a number of possible reasons this could happen. For example, your treatment might not be on your insurance company’s formulary (list of approved drugs), you may be subject to step therapy (where you need to try and fail other treatments before being approved for this one), or a slew of other scenarios, including simple errors that could be corrected easily. 

Understanding the details will be very helpful if you decide to appeal the denial. You may need to address the specific denial language in your appeal, and this documentation will also provide a roadmap for your insurance company’s process of handling appeals. 

Make a game plan with your health care provider

Your health care provider is a critical factor in the insurance appeal process. It’s important that you two are on the same page about what’s best for your disease management and the various actions required during an appeal. Your health care provider will also be able to determine whether you qualify for an “expedited appeal,” which allows you to get an updated coverage decision from your insurance company more quickly. 

Your health care provider may need to play a very active role in the appeal, including writing a letter of medical necessity to help you gain access to the medication. He or she will also have special access to resources designed to help medical professionals navigate insurance appeals, like those offered by the American Academy of Dermatology or by specific drug manufacturers. 

Be thorough

If you decide to appeal the decision, you and your health care provider will have the opportunity to advocate for the importance of accessing your treatment. Depending on why your medication has been denied, you may need to document the severity of your condition, reasons why you can’t take other treatments indicated by your insurance plan or the effectiveness of the medication you’re trying to get covered. 

Writing the appeal letters may involve reviewing medical literature and taking a very close look at your medical records, too. This may seem daunting. Fortunately, NPF has template letters to help. Contact the Patient Navigation Center for more information and to get access to these tools.

Explore other resources

Depending on your treatment and insurance type, your drug manufacturer may be able to connect you with a short-term supply of your prescribed medication while you and your health care provider are appealing the insurance company’s claim.  

If you have health insurance through your employer, it’s a good idea to keep your company’s HR department in the loop as well. They may be able to provide additional opportunities to escalate any issues you have with coverage and advocate on your behalf with your company’s insurance plan.  

Don’t give up!

There are usually at least three different stages to the appeal process. At various points in the process, you’ll have the opportunity to have your claim reviewed by a medical director of your insurance plan or request an external review conducted by an independent reviewer in collaboration with a physician, who is board-certified in the same specialty as your health care provider.

Individual scenarios may vary, but one of NPF’s Patient Navigators can explain what options are available to you.

Get in touch with a Patient Navigator 

Whether you have one insurance question or are in need of ongoing support, our Patient Navigators are here for you. We can help you make sense of what’s happening with your insurance company, share tips about how to access a short-term supply of your treatment and make sure you and your health care provider are on the right track. 

Share your story with us 

NPF’s advocacy team is hard at work to help improve access to psoriatic disease treatments. You can be a part of these efforts, too! We’re always looking for grassroots leaders who are willing to share their story or talk with legislators about the ways they may be helped by current or proposed legislation. 

Remember, you’re not in this alone. If your insurance company denies coverage for a medication you’ve been prescribed, please reach out a Patient Navigator. Give us a call at 1-800-723-9166, email us or send us a question. We don’t want anything to stand in the way of the treatment you and your health care provider choose!

 


Driving Discovery, Creating Community

This year, we’re celebrating 50 years of driving efforts to cure psoriatic disease and improve the lives of those affected. See how far we’ve come with this timeline of NPF’s history. But there’s still plenty to do, and we can’t do it without you! Learn how you can help our advocacy team shape the laws and policies that affect people with psoriasis and psoriatic arthritis – in your state and across the country. Help us raise funding to promote research into better treatments and a cure by joining Team NPF, where you can walk, run, cycle, play bingo or even create your own DIY event. Contact our Patient Navigation Center for free, personalized support for living a healthier life with psoriatic disease. And keep the National Psoriasis Foundation going strong by making a donation today! Together, we will find a cure.

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