It’s an all-too-familiar scenario: You and your doctor think you need a prescription for atopic dermatitis, but your health insurance company thinks differently.
Nearly half of people with eczema have dealt with insurance coverage denials or delays within the past year, according to research.
The process is frustrating, and it can make it harder to keep atopic dermatitis under control, says
Jennifer Gordon, MD, a board-certified dermatologist at Westlake Dermatology in Austin, Texas.
Remember: Just because your claim was denied once doesn’t mean it’ll be denied a second time. There are ways to build a case for yourself that will increase your odds of success.
Insurance rejections can happen for a few reasons, so the best way to find out why the prescription was denied is to call your insurance company and ask directly.
Two of the most common reasons for rejection are:
- Prior authorization, where a practitioner has to get advance approval from an insurance company before a specific treatment will be covered. To do that, your doctor needs to submit detailed documentation to make the case for why you need that treatment.
- Step therapy, where you’re required to try and “fail” other, less expensive drugs before your insurance company will cover the medication your doctor prescribed.
Medications can get denied for other reasons, too. For one, the drug your doctor prescribed may not be on your insurance plan’s list of covered medications. That’s often the case for more expensive treatments, such as biologics, says Hannah Skirrow, lead advocate for the healthcare advocacy platform Solace Health.
You may also be denied if the eczema medication is prescribed by a primary care doctor instead of a dermatologist — even if the prior authorization has been approved and you’ve met all of the step therapy requirements, Skirrow says.
Rejections can also come down to simple paperwork errors. “Sloppy or incomplete prior authorizations cause a huge chunk of first-round denials, and patients pay for a mistake they never made,” says Matt Toresco, founder of Archo Advocacy and Elavay.
Though rejections are often par for the course, especially when it comes to eczema medication, there are things you can do to increase the odds of a first-time approval.
First, try to document as much you can about your eczema and treatment history.
“Call your insurance company and see exactly what they need,” says Dr. Gordon. The more you can show about the meds that haven’t worked, the greater the odds your insurance company will agree to cover the new prescription without a fight.
Keep a running list of the medications you’ve tried already. “Write down the medication name, dose, how long it was used, whether it was effective, and the [healthcare] provider who prescribed it,” Skirrow says. Your dermatologist’s office can help you keep track of your medication history and confirm the information is accurate.
Whenever a medication fails, your healthcare provider should document the lack of improvement in symptoms. If you can include photos, that’s even better, Toresco says. “Then make sure your dermatologist’s office puts all of that failure history into the prior authorization with the right diagnosis codes.”
Typically, your healthcare provider will be the one to submit this documentation to your insurance company as part of the prior authorization process. In most cases, the insurance company will take around 15 days to review the information and notify you and your doctor about whether it will agree to cover the prescription.
You still have options, even if the medication is denied. The first step is filing an internal appeal, where you ask your insurance company to conduct a full and fair review of its decision.
Start by calling your insurance company to find out exactly why you received a rejection.
“Many times, it’s for a simple reason, such as missing documentation showing that other medications were tried and failed or the provider forgetting to include the official diagnosis with the prescription,” says Skirrow.
Once you know why you were denied, you and your doctor can submit the
information your insurance company needs, along with a letter making the case for your appeal. (You can find helpful
sample appeal letters on the Patient Advocate Foundation website.) Insurance companies have 30 days to respond to most appeals.
If your doctor believes you need urgent care, the reply window is 72 hours.
There’s a good chance your insurance company will reverse the decision, as long as the internal appeal was submitted correctly and addressed the reasons coverage was denied the first time, Skirrow says. Up to 80 percent of initial prior authorization denials are overturned, one recent report showed.
If your internal appeal is denied, you can also pursue an external review. That’s where an independent third party — not your insurance company — reviews your case and decides whether the medication should be covered.
The process for external reviews varies by state. “Because of this, it's important to review the applicable state- or plan-specific guidance and follow the required steps when submitting a request,” says Skirrow.
If all of your appeal options have been exhausted and the medication is still denied, pharmaceutical company patient assistant programs can help you avoid paying the full cost of treatment out of pocket.
“If applying for one of these programs, it is important to keep documentation of the insurance denial and any appeal attempts, as this information is often required as part of the application process,” says Skirrow.
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