It is becoming increasingly difficult for doctors and other practitioners in the United States to write prescriptions for expensive medications due to rising healthcare costs. These medications are subject to stringent oversight from third-party payers, also known as insurance companies, as well as pharmacy benefit managers. It is not uncommon for a third-party payer to refuse to pay for a medication that a doctor prescribes to a patient, which ultimately causes a patient to experience a delay in receiving a medication that is medically required. This article focuses on pediatric inflammatory bowel disease to bring attention to the difficulties associated with obtaining prior authorization and being denied treatment. The article discusses the part that pharmacy benefit managers play in limiting access to medications and the factors that can lead to claims being denied for prescription prescriptions that are clinically required. In addition, the post offers guidance on how to conduct a peer-to-peer review properly, how to compose a letter of medical necessity properly, and how to appeal a decision denying your claim. As we move forward into the future, we plan to reform the process, and we will need the advocacy of patients and clinicians.

 

Source: journals.lww.com/jpgn/Abstract/2022/10000/Denials,_Dilly_dallying,_and_Despair__Navigating.7.aspx