This is a question I heard frequently for three years when I worked for a PBM. What is a PBM? It’s a pharmacy benefit manager, a company that manages pharmacy benefits for insurance companies. People usually called and asked that question when their prescription was not approved for fill in their pharmacy. There are a few reasons this happens.
It may be too early to refill your prescription.
There could be an issue with how the prescription is written. Especially where narcotics are concerned, it may be a quantity issue. The pharmacist may need to contact the prescriber to make sure the prescription is correct, especially if some necessary information like dosing instructions are missing. This is sometimes referred to as clarification.
The medication may not be on the formulary. A formulary is a list of drugs the insurance company is willing to cover. Formularies change and a drug that was approved last year may not be covered this year. Sometimes a formulary exception can be requested. This may require the prescriber submitting the request. It’s something that can be inquired about by the patient. If the request is approved the medication cost may be at a high tier, It is worthwhile to inquire about a prior authorization for a tier reduction(lower cost).
The insurance company may require a prior authorization(p.a.) or step therapy for the medication. A prior authorization is a process the prescriber uses to try to justify to the insurance company the need for the medication. Step therapy means the insurance company wants you to use a cheaper medication first to see if it works before approving the medication your prescriber wants you to use.
If the medication is quite new the insurance company may not want to pay for it because of the expense.
Remember insurance companies and pharmacy benefit managers are for profit companies. The more they pay for our healthcare the less their profits are. We must understand their systems in order to be our own advocates.
When speaking with an insurance company or pbm representative take good notes.
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