I submitted a claim last month on behalf of a family member for a compound prescription medication (eye drops with a higher percentage of active ingredient than readily available).
The claim was denied by our PBM because, according to them, it "contains non-covered ingredient(s). Your prescription drug plan does not cover this medication."
The denial did not identify which of the "ingredient(s)" were allegedly not covered.
The compound prescription had four (4) listed ingredients, including sodium chloride (at a cost of seven cents).
Here is what I had to do in order to appeal the claim.
(1) I looked at the original form from the compounding pharmacist and developed a hypothesis that there was only one active ingredient.
(2) I went to the website of our PBM and searched their current formulary. I found the same delivery system of the same active ingredient (at a different concentration) listed, and printed out the page proving that the active ingredient was covered.
(3) I went to DailyMeds and printed out the drug information, including the ingredients list, confirming my hypothesis about which of the four ingredients was the active one and also proving that the three inactive ingredients in the compounded prescription were also used as a buffer in the formulary drug.
(4) I filled out the appeal packet, explaining all this and attaching the denial letter, the claim showing the list of ingredients, the page from the formulary showing that the medication was generally covered and the drug information showing that the inactive ingredients were the same.
(5) I mailed the appeal certified mail, return receipt requested, because I don't trust these people to keep track of anything anymore.
The worst part of all this is that the compounding pharmacy charged us less than the listed price of the formulary drug. So going this route should save the PBM money.
Of course, just denying the claim outright was even cheaper.
But I have to wonder. What do people do without good research and verbal skills and some knowledge of chemistry?