Insurance Appeal Information for High Epinephrine Cost / Denial of Coverage
FARE believes that all individuals with food allergies should have affordable access to life-saving epinephrine. Epinephrine is the only medication that can reverse the symptoms of a severe life-threating allergic reaction, known as anaphylaxis.
When an insurer does not provide affordable access to epinephrine—either by refusing to cover the medication or only covering a small amount of the cost—you can initiate an appeals process through your insurance carrier.
Under the 2010 Affordable Care Act (ACA), all insurers, including Medicare and Medicaid, must have an appeals process in place.
Patients may file an appeal if an insurer:
- denies a request for coverage or payment of a prescription that a patient thinks he should be able to get;
- denies payment for a prescription that a patient has already received;
- changes the amount a patient is requested to pay for a prescription; or
- stops covering or paying for part or all of a prescription that was covered/paid for previously.
If any of the above apply to you, here are some guidelines for beginning the appeals process:
- Start by reviewing your insurance plan documents. If epinephrine is specifically excluded from the policy, chances of winning coverage for it on appeal are slim. If the policy does not mention an exclusion of epinephrine, or the coverage is unclear or framed in terms of medical necessity, it is to your advantage to move forward with the appeals process.
- Review the official response to your claim, known as the Explanation of Benefits (EOB). Make sure you understand why the prescription was denied or why more of the cost was not covered. These explanations often appear as codes with explanatory notes at the bottom or on the back of the EOB. Make sure there are no errors in the billing code, patient identification number, date of service, or other information. These errors can often be resolved with a phone call. If all of the information is correct, your next step is to prepare for your appeal.
- Review your plan's appeal procedures, which are often found in a section called "Grievances and Appeals.” Once you have reviewed the appeals process, follow the plan’s appeals procedures carefully and be sure to stay on top of deadlines.
- Be sure to discuss the denial with your doctor. His or her support in the form of a letter citing medical necessity for epinephrine could be invaluable. Download a sample letter of medical necessity.
Here are some tips as you go through the appeals process:
- Write a clear and concise letter. Provide a simple explanation of why you believe the prescription should be covered. Keep your letter to one page. Be sure to include your insurance identification number, the claim number, date of claim, and the contact information of the provider who wrote the prescription. Download a sample letter of appeal.
- Keep thorough records. Record all interactions with your insurer, including names of insurance employees you speak to and the dates you speak to them. Save copies of claims and bills, appeal letters, emails and any other relevant communications.
- Pursue your appeal. If your appeal is denied, go to the next level of appeal. This is not automatic, so make sure you request a second-level, or external, review. This is a re-consideration of your original claim by professionals with no connection to your insurance plan. If the external reviewers think your plan should cover your claim, your health plan must cover it.
Additional Tips and Resources
- If your insurance company requires you to get prescriptions by mail to receive a reduced price, it is not advisable to do so unless you can be assured that the auto-injector will be protected from heat and cold.
- If you have a children’s hospital nearby, find out what support or grants it may provide to help you pay for the prescription.
- Consider changing your health insurance plan.
- Check pricing with different pharmacies in your area.
Patient Assistance Programs
Mylan Specialty, make of EpiPen®, offers patient assistance programs to those who qualify. Learn more:
Coupons are available from some manufacturers of some epinephrine auto-injectors. Depending on your insurance, the coupon may reduce your cost to $0. Learn more: