A couple of months ago, my insurance paid for a medication that I assumed had prior authorization ¶ approved by my doctor. Now that I’m trying to refill it, the insurance company tells me the PA was denied and no additional information was submitted. My doctor’s office says the PA was initially denied because I didn’t meet the criteria, but they sent in additional information after I completed a couple of medication trials.
The pharmacy said the medication was covered at the time, so I thought the PA had been approved. Why would my insurance pay for the medication if the PA was denied? Do I need to worry about paying that money back? Is this something the doctor or pharmacy should fix, or do I need to do something now?
It’s possible the medication was paid through a process called denial conversion, where a manufacturer automatically covers denied claims with a voucher. This can happen without the pharmacy being aware, as it looks like a normal insurance transaction. If that’s the case, you wouldn’t owe the money back, but you can call your insurance or check your Explanation of Benefits (EOB) to confirm how it was processed.
Carter said: @Ainsley
I checked my insurance portal, and it shows the claim was paid by my insurance. Does that mean it wasn’t a denial conversion?
If the insurance shows they paid it, you should call to confirm why. It could be a transitional fill, where insurance covers the medication temporarily while a PA is under review. Errors are rare but can happen, and it’s better to find out now than risk a surprise bill later.
Some medications only require prior authorization for long-term use. It’s possible the initial fill didn’t trigger the PA requirement, but subsequent refills did. If your medication needs a PA the whole time, this might not apply here.
If it was a mistake, the insurance or pharmacy might catch it eventually. You can call the insurance company to ask why it was covered the first time and confirm what’s needed moving forward. Sometimes they have processes for transitional fills, which might explain this.
It might be worth asking your doctor’s office if they can follow up on the prior authorization to see if the additional information was submitted properly. If it wasn’t, they might need to resend it.
Some insurances allow a one-time courtesy fill while they process a prior authorization. Check your EOB or call to see if that’s what happened in your case.