My appeal was approved but the pharmacy still charges full price. What happened?
Two bodies decide two different things: the insurer decides medical necessity, the plan sponsor decides whether the drug is a covered benefit at all. A medical-necessity approval cannot add back a benefit the employer or program excluded, so get the pharmacy reject code and then write to the sponsor for a written determination.
What to do, in order
- Step 1
Get the reject code from the pharmacy
Ask for the rejection code and message on the claim. "Prior authorization required" means the approval never loaded and the administrator must fix it. "Plan exclusion" or "not a covered benefit" means the plan sponsor is the decision-maker, and the insurer's approval letter will not move the pharmacy.
- Step 2
Write to the sponsor, not the insurer
Send your HR benefits contact (or the program office for public employees) a short letter with the approval attached. Ask whether the plan honours it and, if not, for the plan provision relied on, quoted, and the page of the plan document that carries the exclusion. Most employer plans are self-funded: the employer writes the benefit list and the insurer only administers it.
- Step 3
Put the diagnosis on the record
If the drug was prescribed for a condition outside the excluded category (PCOS or sleep apnoea rather than weight loss, for example), have the prescriber state the diagnosis and reason in one paragraph. Exclusions are written by category; whether yours is inside it is a fair question to put in writing.
- Step 4
Use the plan's own appeal path
A self-funded private plan is under ERISA and must give you the specific reason, the provision and, on request, the claim file. Governmental plans sit outside ERISA but have a written appeal procedure in the member handbook; ask for it by name and file within its deadline.
The deadline that applies
For an ERISA or ACA plan you have at least 180 days from the adverse notice to appeal (29 CFR 2560.503-1; 45 CFR 147.136). Governmental and church plans set their own windows in the plan document, often shorter. The written notice controls; if there is no written notice, ask for one in writing and date your request.
Calculate your date →Documents to gather
- The insurer's approval letter, with the case number
- The pharmacy claim rejection (code and message)
- The sponsor's notice removing the benefit, and the plan amendment if any
- The prescriber's one-paragraph statement of diagnosis and reason
- The plan document page carrying the exclusion, once the sponsor sends it
Go deeper
Related questions
Can the employer stop covering a drug mid-year?
Usually yes, with notice, if the plan document allows amendments. The notice and the amendment language are what you ask for.
Does the insurer's approval bind the employer?
Not by itself. It binds the administrator on medical necessity. Whether the sponsor honours it is the question you put to the sponsor in writing.
Is this a state insurance department matter?
Only if the plan is fully insured. Self-funded employer and governmental plans are not regulated by the state insurance department.
Sources
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