If I pay for a prescription will it be harder to get reimbursed?
July 20, 2024 1:03 PM Subscribe
I have a pending new prescription and a pretty good US prescription plan. My doctor warned me the insurance companies frequently try to avoid paying for this particular medication, and then suggest poorer options instead. Sure enough the pharmacy received a request for justification from my doctor. The pharmacy has submitted the needed paperwork for my doctor to fill out, but it's been 3 days and I still don't have the medicine.
If I pay out of pocket ($1,000) for this medicine, does that make getting the money back less likely? I mean, let's say there is a 50% chance my doctor's arguments work, and then I get the prescription for free. Would the chances be less than 50% if I pay in advance and then have to claim the money back?
My employer doesn't have staff who can/will intervene with the insurer.
It is a covered medication under my plan on the official list.
If I pay out of pocket ($1,000) for this medicine, does that make getting the money back less likely? I mean, let's say there is a 50% chance my doctor's arguments work, and then I get the prescription for free. Would the chances be less than 50% if I pay in advance and then have to claim the money back?
My employer doesn't have staff who can/will intervene with the insurer.
It is a covered medication under my plan on the official list.
Best answer: No answers but some questions that might help you think through the overlapping risks here
There are two probabilities:
1. will it get approved?
2. If it approved, will they reimburse you if you already paid for it?
One complication is that if your pharmacy is in-network, the cost of the drug to you is a combination of the discount that the pharmacy gives the insurance company plus the amount that insurance company pays the pharmacy. So if the pharmacy charges you $1000 but only charges insurance $750, the insurance is not going to pay for the extra $250 even if they otherwise cover it. The way around it is to see if the pharmacy will file the claim directly once you know that it has been approved. Doctors offices can do this, you would have to ask your pharmacy if it is an option.
The second complication is where the approval is effective retroactively as of the date the doctor filed for it or the date that it is approved. I went and looked at one of my preauthorization approvals and it shows the date the doctor requested and the date the approval expires but it doesn't say anything about when it starts. You could try calling the insurance company and asking but honestly I don't have much confidence that you would get a correct answer. If they say no, I would still try. If they say yes, make sure you write down the reference number for the call. (Although they still won't take responsibility for the own staff giving bad advice)
posted by metahawk at 1:31 PM on July 20, 2024
There are two probabilities:
1. will it get approved?
2. If it approved, will they reimburse you if you already paid for it?
One complication is that if your pharmacy is in-network, the cost of the drug to you is a combination of the discount that the pharmacy gives the insurance company plus the amount that insurance company pays the pharmacy. So if the pharmacy charges you $1000 but only charges insurance $750, the insurance is not going to pay for the extra $250 even if they otherwise cover it. The way around it is to see if the pharmacy will file the claim directly once you know that it has been approved. Doctors offices can do this, you would have to ask your pharmacy if it is an option.
The second complication is where the approval is effective retroactively as of the date the doctor filed for it or the date that it is approved. I went and looked at one of my preauthorization approvals and it shows the date the doctor requested and the date the approval expires but it doesn't say anything about when it starts. You could try calling the insurance company and asking but honestly I don't have much confidence that you would get a correct answer. If they say no, I would still try. If they say yes, make sure you write down the reference number for the call. (Although they still won't take responsibility for the own staff giving bad advice)
posted by metahawk at 1:31 PM on July 20, 2024
If it's a covered medicine on the formulary, why are they jerking you around like this? Unless it's specified as non-preferred and/or needing prior authorization, I would try calling with that angle in mind, because identifying the specific problem may inform the likelihood of reimbursement.
posted by teremala at 1:46 PM on July 20, 2024 [2 favorites]
posted by teremala at 1:46 PM on July 20, 2024 [2 favorites]
Response by poster: Teremala, I don't know the backstory, and I can't know until Monday when the insurance company opens. But the pharmacy is open now.
Wintersweet, sure go ahead.
posted by lockedroomguy at 1:51 PM on July 20, 2024
Wintersweet, sure go ahead.
posted by lockedroomguy at 1:51 PM on July 20, 2024
Somewhat unrelated but maybe helpful in weighing reimbursement possibility...
Short version: I went into the ER at 11 PM, left at 9 AM, and insurance said I owed two identical copays for the same visit. Supposedly the hospital billed it as two visits on two subsequent days, which I don't actually see in their billing, but insurance says that's why two copays. They explicitly said they will not reimburse the second copay if I paid it to the hospital now and it is later determined to be invalid. I didn't take the chance and I disputed the second copay with both insurance and the hospital (to keep the latter from sending it to collections in the meantime).
All of that to say, even if everything else goes 100% in your favor, I agree with metahawk that you won't get reimbursed for the difference between the cash price and whatever your insurance would end up paying the pharmacy. The rest of it is less certain but still very, very iffy.
posted by tubedogg at 2:38 PM on July 20, 2024
Short version: I went into the ER at 11 PM, left at 9 AM, and insurance said I owed two identical copays for the same visit. Supposedly the hospital billed it as two visits on two subsequent days, which I don't actually see in their billing, but insurance says that's why two copays. They explicitly said they will not reimburse the second copay if I paid it to the hospital now and it is later determined to be invalid. I didn't take the chance and I disputed the second copay with both insurance and the hospital (to keep the latter from sending it to collections in the meantime).
All of that to say, even if everything else goes 100% in your favor, I agree with metahawk that you won't get reimbursed for the difference between the cash price and whatever your insurance would end up paying the pharmacy. The rest of it is less certain but still very, very iffy.
posted by tubedogg at 2:38 PM on July 20, 2024
Can you ask the pharmacist to charge you the price that they would charge to your insurance? I have heard that can be an option but I’ve never tried it myself.
posted by xueexueg at 2:42 PM on July 20, 2024 [1 favorite]
posted by xueexueg at 2:42 PM on July 20, 2024 [1 favorite]
Best answer: In instances like this, I use a local non-chain pharmacy. I ask that they bill the insurance, but to expidite the filling of the prescription, I will lay out the insurance money now if they agree to return it to the credit card if/when big insurance pays. I guess it helps that I have been going to this pharmacy for over two and a half decades and one of my kids playing on the same little league team as the pharmacist's kid, but they will do it. By doing this, the insurance company does not know I laid it out and thinks they don't have to reimburse me.
I have done this twice for smaller amounts than $1,000. You are dealing with BIG insurance. It is my opinion that if you lay it out hoping to get reimbursed, they have less incentive to pay you back. I have no facts, just common sense at how a big company works. YMMV.
posted by JohnnyGunn at 3:32 PM on July 20, 2024 [1 favorite]
I have done this twice for smaller amounts than $1,000. You are dealing with BIG insurance. It is my opinion that if you lay it out hoping to get reimbursed, they have less incentive to pay you back. I have no facts, just common sense at how a big company works. YMMV.
posted by JohnnyGunn at 3:32 PM on July 20, 2024 [1 favorite]
I could be wrong but I'm getting glp1 vibes from this. If glp1 drugs aren't covered by your plan, this will not get approved and this will not get paid for. Reimbursement is moot. This is the hottest issue this year in prescription plans. The insurers will not play, there is no flexibility.
posted by phunniemee at 3:33 PM on July 20, 2024 [1 favorite]
posted by phunniemee at 3:33 PM on July 20, 2024 [1 favorite]
Best answer: Did your doctor use the words "prior authorization"? It sounds like you're going through the prior authorization process. Paying for the drug out of pocket does not impact prior authorization. However, most insurances don't reimburse retroactively. The authorization is for the date from which they approve it, not before. There are some exceptions and you can ask your insurance specifically their policy on refunding medications paid for out of pocket but I wouldn't count on being paid back any amount regardless of whether or not it's approved.
The prior authorization process also often means you must try other medications first before they will pay for this one. This is called step therapy. Your doctor can try and justify it but often if you have not tried their preferred medications they will not cover this one until you do. Of course if you try it and it doesn't work or you have side effects, you can then submit that to the insurer and then hopefully get the other med approved. But unless your doctor has strong evidence there's a reason you can't be on the other meds, it is unlikely the insurance company will approve it without you at least trying those meds.
posted by brook horse at 3:52 PM on July 20, 2024 [3 favorites]
The prior authorization process also often means you must try other medications first before they will pay for this one. This is called step therapy. Your doctor can try and justify it but often if you have not tried their preferred medications they will not cover this one until you do. Of course if you try it and it doesn't work or you have side effects, you can then submit that to the insurer and then hopefully get the other med approved. But unless your doctor has strong evidence there's a reason you can't be on the other meds, it is unlikely the insurance company will approve it without you at least trying those meds.
posted by brook horse at 3:52 PM on July 20, 2024 [3 favorites]
Best answer: Is it the kind of drug your prescribing doctor might give you samples of until its approved?
I take some stupid expensive meds that even my amazing insurance requires prior auth on. I got through the wait with doc provided samples.
posted by atomicstone at 4:06 PM on July 20, 2024
I take some stupid expensive meds that even my amazing insurance requires prior auth on. I got through the wait with doc provided samples.
posted by atomicstone at 4:06 PM on July 20, 2024
This may be an issue of not just prior auth but “step therapy” or “fail first” where insurance companies insist you try out cheaper therapies and “fail” on them before they will approve other more expensive drugs, even if the latter is on the formulary.
Unfortunately I’m not familiar enough with it to know if/how to fight it, but thought I would bring it up in case that helps with talking to the doctor, pharmacy, insurer or doing other research.
I suspect you’ll need your doctor to go to bat for you, and at that price point I would not self-pay unless I was truly ok with never being reimbursed.
posted by misskaz at 4:18 PM on July 20, 2024 [3 favorites]
Unfortunately I’m not familiar enough with it to know if/how to fight it, but thought I would bring it up in case that helps with talking to the doctor, pharmacy, insurer or doing other research.
I suspect you’ll need your doctor to go to bat for you, and at that price point I would not self-pay unless I was truly ok with never being reimbursed.
posted by misskaz at 4:18 PM on July 20, 2024 [3 favorites]
You should talk to your insurance company and find out what approval process the prescription is going through, how long that will take, and whether you will be reimbursed if you pay out of pocket and they subsequently approve the drug.
You could also ask whether there is anything you can do to expedite the process.
posted by Winnie the Proust at 4:23 PM on July 20, 2024 [2 favorites]
You could also ask whether there is anything you can do to expedite the process.
posted by Winnie the Proust at 4:23 PM on July 20, 2024 [2 favorites]
Response by poster: Thanks all!
Marked a couple of best answers that answered the question, and a couple with particularly useful side info. But all helped!
posted by lockedroomguy at 3:47 AM on July 21, 2024
Marked a couple of best answers that answered the question, and a couple with particularly useful side info. But all helped!
posted by lockedroomguy at 3:47 AM on July 21, 2024
Best answer: If the medication/pharma company has any sort of "patient navigator" type contact listed on the website, they can often help, too. They're financially interested in getting people on their meds and can help all the entities (doctors office, insurance, pharmacy) get aligned. And they're the ones giving samples to the doctor and can sometimes help with that, too.
posted by lapis at 7:36 AM on July 21, 2024
posted by lapis at 7:36 AM on July 21, 2024
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posted by wintersweet at 1:12 PM on July 20, 2024 [1 favorite]