Why is Nothing Covered?

Prescription drug insurance should be a comforting benefit. But many consumers are distressed when their pharmacies refuse to cover select medications, especially when the drug was covered the month before.

Jerome Carpenter said he just can’t determine what he’s doing wrong. Every time I go to the pharmacy I have to pay cash for my medication because my insurance won’t cover it, he complained. Am I doing something wrong??

The only thing you’re doing wrong is expecting your insurance plan to demonstrate logic and reason. Unfortunately, benefit plans are generally restrictive and rigid. As one consumer complained, they seem more interested in rules than common sense.

Many plans, for example, require members to obtain advance authorization for select medications. That is a reasonable way to prevent excessive use of expensive medications. However, overly restrictive approvals can backfire.

My doctor initially told me to take six 5 mg tablets of a certain medication each day. I obtained the necessary authorization from my insurance company and obtained the medication. The next time I went to the doctor, he changed the prescription slightly.

He said the medication would cost less if he prescribed three 10mg tablets daily instead, a New York man explained. Higher strength pills may be more commonly prescribed and commonly available, and consequently less expensive.

But the plan backfired. My insurance company wouldn’t pay for the medication, even though I was taking the same daily dose and the total cost of my prescription was less. The insurance representative said I only had approval to obtain 5 mg tablets.

Insurance companies may also refuse coverage if you try to refill a prescription even a day or two early. Most require consumers to wait a full 30 days between refills.

They can also refuse coverage or increase your co-pay if you ask for a medication that is not on the company authorized preferred drug list. The preferred list, called a formulary, specifies the medications the insurance company prefers you to obtain in each class of medications.

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