How to Navigate the Health Care System for Drug Therapy
In today’s increasingly complex health care system, it can be important to know the ins and outs of prescription insurance coverage in order to receive the medication that is intended by your doctor.
“With adequate knowledge, rosacea patients are empowered to take proactive measures that may be necessary to receive medical therapy appropriate for their individual cases,” said Dr. John Wolf, chairman of dermatology at Baylor College of Medicine. “This can be especially important when prior authorizations and ‘step edits’ are required.”
For example, your health insurance provider may require your physician to submit a Prior Authorization (PA) form to justify the use of the drug before you can be prescribed the medication and your insurance will pay for it. There are various reasons this might occur. The medication may be expensive; it may be approved and primarily used to treat a different disease or a certain age group; or the insurer may require an explanation of the medical necessity of the drug for your disease.
In any of these cases, your doctor must fill out the PA form and fax or mail it to the insurance company along with the prescription. The pharmacist will fill the prescription only after the insurance company approves.
In other cases, health plans may require that another drug be tried before a particular medication may be prescribed; this is known as a "step edit." If the drug your physician prescribed is step edited by your insurer, the pharmacist will check your prescription history to see if you've used the insurance company's preferred first drug in the last 6 to 12 months. If you haven't, the pharmacist will call your doctor and ask him or her to switch the prescription.
While either of these scenarios can mean a delay or change in treatment, here are some things you can do to help navigate or speed up the process.
- Each insurance provider's website will have its own formulary listing of drugs it will pay for, noting those that require prior authorization or a step edit. Check the site when you receive a new prescription to see if it requires further processing. Rosacea drugs are usually listed under “Dermatology/dermatologicals.”
- If the drug you've been prescribed requires prior authorization, make sure the PA form is submitted right away by your doctor’s office; often it may be processed in as little as 24 hours. Meanwhile, ask your physician if he or she has samples of the medication that you can take while you wait for the approval to go through.
- Make sure your doctor knows which rosacea therapies you have tried, whether they worked and why you stopped or wish to change. This can be important if the newly prescribed medication happens to be step edited.
- If the medication is denied by your insurer, call to find out why, and discuss alternatives with your physician. If coverage is through your employer, ask the human resources department why the medication has a prior authorization or step edit requirement.
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The National Rosacea Society is a 501(c)(3) nonprofit organization whose mission is to improve the lives of people with rosacea by raising awareness, providing public health information and supporting medical research on this widespread but little-known disorder. The information the Society provides should not be considered medical advice, nor is it intended to replace
consultation with a qualified physician. The Society does not evaluate, endorse or recommend any particular medications, products, equipment or treatments. Rosacea may vary substantially from one patient to another, and treatment must be tailored by a physician for each individual case. For more information, visit About Us.