Treatment not covered

I have a chronic health condition that has not responded to any of the usual treatments.  My doctor suggested a drug that might work – a monthly injection.  My plan won’t cover it because they say it is experimental.  This drug is already used for other illnesses – why won’t they cover it for me?  And what can I do to get it covered?  It’s very expensive!

Still Hopeful

Dear Still Hopeful,

Your health plan is required to review claims that have been denied and that the member disagrees with.  It’s called an “appeal” process.  You should have received a letter from the plan stating that they would not pay for the treatment, and telling you how to appeal the decision.

Your doctor can help you do this.  You will want a letter from him or her describing how the other treatments have failed, and why the drug is being suggested.  You can also write your own letter.

The plan will first have what is called an “internal” review.  This internal review will be done by people at the health plan who were not involved in the earlier decision.  You may get the treatment covered as a result of this review.  If not, you can go further and request an “external” review.  An external review will be done by people outside of the health plan’s staff.  These people are contracted by the health plan, but don’t worry: they have to be objective and their contracts are set up so that they do not get paid more for agreeing with the health plan’s decisions.

If the external review still doesn’t go your way, then you could look into being part of a clinical trial.  The drug may be going through a trial for people with your condition.  You can search the National Institute of Health’s Clinical Trials Registry.  The trial itself would provide the drug to you for no charge and may provide other services too; your health plan would still pay for services that would normally be covered, such as office visits.

Don’t give up!


Linda Riddell

About Linda Riddell

A published author and health policy analyst with 25 years’ experience, Linda Riddell's goal is to alleviate the widespread ailment of not knowing what your health plan can do for you.