What do I do when my medical benefits for prescription drugs have been terminated?
(Column: Ask the Pharmacist)
Steve Kaufman, RPH
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In the world today with computers and electronic submission of data many patients find that their medical benefits have been terminated, sometimes without any warning.

Most patients are covered by some sort of medical plan. Either private insurance (Blue Cross, Oxford, HIP, Cigna, etc.), or through government plans (Medicaid, Medicare). Many of us have experienced or know someone who has experienced going to the pharmacy to pick up their prescription only to be told that their insurance company has rejected the claim.

This is what you do if you coverage is terminated. First, call your carrier and ask them why. Remember just because you were covered yesterday it does not mean that you are covered today. Here are the most common reasons coverage might be terminated: 1) the insurance company made a mistake; 2) you have been transferred from one insurance company to another; 3) many times an insurance company will discontinue a policy and reissue a new policy with new ID numbers and many times patients are unaware of the change; 4) in cases of Medicaid recertification papers either have not been filled out or have gotten lost.
Question 2: What you do if your coverage is terminated or you have no coverage or your insurance or HMO does not pay for the medication?

Answer: There still are some options available if you have no coverage or your HMO refuses to pay for your medication. Speak to your pharmacist or doctor, most pharmaceutical companies have some sort of patient assistance programs. If you have no coverage for the medication and cannot afford to pay for it many of the pharmaceutical companies will provide it to you free of charge. There is paperwork that has to be done to qualify for these programs, so get started on it as soon as possible. It is usually best if you get all the information together and give it to your doctor so he has to do as little as possible (many doctors do not have the time to sit on the phone trying to get this kind of information). Another option is local associations many times can help you get medication or get funds to pay for medications. For example, if you are diabetic and need your diabetes medication, call the American Diabetes Association and ask if they can help. Most doctors and pharmacies can get these telephone numbers for you.

Remember you must take your medication correctly for it to work. Make sure your insurance company knows how important it is for you to take your medication. Tell them what the consequences are if you don't take your medication. Insurance companies do not want lawsuits. If the problem is on their end, you need to tell them how much medication you have left and how quickly the problem needs to be solved. For example, if you have only a day of medication left and your insurance company says they will reinstate you in 72 hours, tell them that is not acceptable, and ask them to let you speak to a supervisor. Insurance company or HMO supervisors can override the system.

Good luck and stay healthy!
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