What can I do if my health insurance has denied a prescription for a diabetes drug that my endocrinologist prescribed for me?

The cash price is prohibitively expensive. My doctor appealed and gave them numbers and lab work results showing the great results of the sample period that I had tried but still was denied. Do I have any further recourse? This is a major quality of life issue for me.

Asked on November 25, 2013 under Insurance Law, Washington


M.T.G., Member, New York Bar / FreeAdvice Contributing Attorney

Answered 7 years ago | Contributor

I am so sorry.  It is unfortunate that you treatment comes under such close scrutiny by some one that has never met you: the insurance company doctor that decides if the treatment is covered. Coverage can be disclaimed for a host of reasons but it is their job to determine if it is "medically necessary" for coverage.  Treatments that are experimental or really new do not generally have a chance to be covered under your plan.  And if the drug was not specifically targeted toward your illness (sometimes it is found that a drug issued for one ailment really helps another) can also be an issue.  Was what your doctor did considered a formal appeal of the denial?  That is always the first step. In many states you may also be entitled to an independent State Board Review of the determination.  Contact your State Department of Insurance and find out the procedures.  It may even be beneficial to you to consult with an attorney in the field to determine what your state allows.  Good luck.

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