You leave the doctor’s office with a new prescription, take it to the pharmacy, and then hear:
“Your insurance doesn’t cover this.”
Frustrating? Absolutely. But it doesn’t always mean you can’t get the treatment you need.
The important thing to remember is this: your doctor knows what they want to prescribe, but they may not know what your specific insurance plan prefers or covers.
Prescription Insurance Problems: Ask What Is Covered
If your insurance denies a medication, don’t stop at “no.”
Call the insurance company and ask:
What medications in the same drug family are covered?
Is there a preferred medication they want you to try first?
Is there a lower-cost alternative on the formulary?
Then take that information back to your provider and ask whether one of those options would work for you.
Sometimes the solution is not fighting for the original prescription. It’s finding the right medication your insurance will actually cover.
When It Really Does Need to Be That Exact Medication
Sometimes the prescriber wants a specific brand, manufacturer or exact product.
That’s when DAW 1 — Dispense as Written — matters. It tells the pharmacy the prescriber specifically wants that product and does not want substitution.
Patients can also request a specific manufacturer or brand using DAW 2, meaning the request came from the patient.
That can be helpful when you’ve had:
Side effects with one manufacturer
Problems with inactive ingredients
Trouble identifying constantly changing tablets
The dreaded generic square dance every time the pharmacy changes suppliers
Prior Authorization? Follow the Right Trail
If your medication needs a prior authorization, the pharmacy usually starts the process by sending the request — but the provider’s office has to complete it.
So don’t keep calling the pharmacy asking whether it’s approved.
Call the provider’s office and ask to speak with the person who handles prior authorizations.
Then follow up until you have an answer: approved, denied or more information needed.
Once the provider’s office completes the process, the pharmacy receives the result.
A Little Pharmacy Know-How Goes a Long Way
Insurance problems at the pharmacy can feel like a brick wall. Often, they’re really more of a maze.
Knowing who to call, what to ask and what your options are can save you days of frustration — and sometimes quite a bit of money.
And remember: the goal isn’t necessarily to get the exact medication originally written.
It’s to get the right medication for you.
For related reading, see How Aging Changes the Way Medications Work.
For more information about Medicare drug coverage restrictions, see Medicare’s explanation of drug plan rules.
Need Help Getting Unstuck?
If you’re caught between the pharmacy, the insurance company and the provider’s office and aren’t sure who to call or what to ask, I can help you sort through the options.
Ask the Advocate gives you focused, one-on-one guidance for one healthcare problem — including medication access and insurance roadblocks.
PRO TIP: Most times typing 0#0#0# at the beginning of an automated phone system can confuse the system and send you to a person. 😉
✨ Stay confident. Stay informed. Stay Taylormade.
Cheers!
Dr. T