Phone script: pharmacy rejection
What to ask at the pharmacy counter and then your plan when a prescription is rejected, so you learn why and what to send.
- Private: nothing leaves this tab
- A template, not legal advice
When to use this, and what it is not
When to use this. When a pharmacy says your insurance will not pay for a prescription. A pharmacy rejection is not a written decision from your plan. Ask the plan for its decision in writing, because the written notice carries your appeal rights.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the script
Your script
Date of this call: [Date of the call] At the pharmacy counter: 1. Ask: "What exact message did the insurance send back? Please write it down." Record it here: [The exact message the pharmacy gave]. 2. Ask: "Is it a prior approval, a quantity limit, a refill too soon, or a drug that is not covered?" 3. Ask: "Can you call the plan's pharmacy line to ask about a short supply?" Ask: "What would it cost without insurance today?" You do not have to decide today. 4. Ask: "Please contact [Your prescriber's name] about a prior approval or another covered drug." Then call your plan (number on your card): 5. Say: "I am [Your name], member identification (ID) number [Member ID]. [The pharmacy] could not fill [The drug, strength and amount]. The message was: [The exact message the pharmacy gave]." 6. Ask: "Is this drug covered? Does it need a prior approval, step therapy or an exception? What does my prescriber need to send, and where?" 7. Ask: "How long will the decision take? Please send it to me in writing, with my appeal rights." 8. If you have a Medicare drug plan, ask: "Is this a coverage determination? I understand you must answer within 72 hours, or 24 hours if fast." If you are in your first 90 days with the plan, ask about a transition supply. 9. Ask for the person's name and a call reference number. Ask whether the call may be recorded, and write down their answer. 10. Write down: name, ID number, date, time, reference number, the promised action and the date. Read it back and say, "Thank you."
Before you call
Ask the pharmacist at the counter first, then call the member services or pharmacy number on the back of your insurance card. Ask for a call reference number at the start and again at the end of the call.
What happens next
- Ask your prescriber to send whatever the plan needs. A prescriber's supporting statement is required for an exception request under Medicare drug plans.
- If the plan denies the drug in writing, read the notice for your appeal deadline and ask for the plan's reasons.
- If you take a medicine you cannot go without, tell your prescriber and the pharmacist today and ask what the options are.