You pay all this money for insurance, and the insurance won’t cover your medications. What is going on? Your provider believes that this medication is right for you. But your insurance has the final say. Who’s is the doctor here? So you call your doctor’s office to let them know that the medication is not covered. The doctor is very busy and you only get through to the medical assistant. By now it’s going on two weeks without your prescription medication and you are starting to panic. You’re feeling out of control. Your medication is in the hands of the medical assistants and your insurance. You or your provider no longer have control. And every time you call the doctor’s office, it’s a 20 minute hold before you can speak to anyone. And every time you call the insurance company, you’re on the phone for at least 30 minutes only to have your phone call disconnected, so frustrating!
pharmacy benefit manager
When your medication is not covered by your insurance, also known as your pharmacy benefit manager or PBM, there are steps you can take to gain control of the situation, and not have to rely on going back-and-forth with the doctor’s office and the PBM and being placed on hold for hours on end.
First of all, be accountable and educated about your own care. When your doctor prescribes you a new medication, call the pharmacy benefit manager on the back of your card, and ask them if it is covered, this is called the formulary. Is this prescription on your formulary? Your provider will not know if it is on your formulary. Each insurance has a different formulary. On top of that, every year your formulary changes. It is impossible for the provider to keep track of which medication is on each and every one of their patients’ formulary.
While you have your PBM on the phone, ask them which medications are similar to the one prescribed that is on the formulary. Write these down so you can inform your provider of what is covered. If you and your provider believe that these formulary drugs are not right for you, then most likely, a prior authorization (PA) is needed for this new prescription medication that is not on formulary. A PA is a request from the doctor to your PBM to cover the medication. Only your doctor can make this request.
When requesting your doctor’s office to complete a prior authorization (PA) for this non formulary drug, keep a record of the date and person you spoke with at the doctor’s office. Once the doctor’s office submits the PA to your insurance, it is no longer in the hands of the doctor. It’s up to you to follow up with your PBM. Only the PBM will know the determination, they will mail or call you with the final decision, they normally do not let the doctor’s office know. Follow up with your PBM or your pharmacy.
If you need help and you have questions about prior authorizations and formulary drugs, Signature Nurse can help. We can make your phone calls for you at your home providing you allow us to handle your protected health information (PHI). Call us at 714-602-1193 or visit us at SignatureNurse.com
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