Rejected Claims


If an insurance company will not cover the cost of a prescription medication you have been prescribed you may consider the following:

  1. Call the Benefits department of the insurance company (have your benefits policy number, employer's name and the drug identification number (DIN) of the medicine you have been prescribed with you) to make sure that they are not covering the medication. Ask why they won't cover it.
  2. Let the Human Resources manager at your employer know what the insurance company told you and let her/him know your physician wants you to receive this medication and has prescribed it for you. Have her/him contact the insurance company.
  3. Determine if it is the decision of the insurance company not to cover the drug or if it is specifically excluded by the plan your employer has purchased.
  4. If your employer has purchased a drug plan for employees that doesn't cover your prescribed medication, they have the option of making an exception for this medication in this instance. Ask your employer to have the drug covered.
  5. If it is the decision of the insurance company not to cover the drug you can have your physician write a letter of appeal to the insurance company, giving the reasons why you need this medication. If the appeal is rejected you can contact the insurance company's ombudsman to file a complaint and request reversal of their decision.
  6. If you are part of a patient support group ask if others have had a similar experience to yours

If a provincial/territorial drug benefit program will not cover the cost of a prescription medication you have been prescribed you may consider the following:
  

  1. Have your physician write an appeal letter to the drug program giving all the reasons why this medication is necessary. Make sure all the information the drug program requires is included in the letter.
  2. Call and write to the drug program requesting an explanation of their decision
  3. If you are part of a patient support group ask if others have had a similar experience to yours
  4. Contact your provincial Minister of Health and MLA regarding your situation and request that the drug be covered for you.

Special Authorization Claims/Requests
  

The above advice also applies in the case of a rejection of a special authorization drug claim. Some insurance companies and provincial/territorial drug benefit programs set criteria or guidelines for the use of specific drugs. They may also require specific clinical information be included in the claim letter/form. Have your physician's office contact the insurer to determine if usage guidelines exist for the drug you have been prescribed and also what information should be included in the special authorization request. Using the sidebar menu, you can visit the different drug benefit programs and find out what their special authorization policy is. Some programs have the criteria/guidelines for special authorization medications listed.