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4 COMMON MEDICATION-RELATED INSURANCE REJECTIONS PROVIDERS SHOULD UNDERSTAND

Written by Alex Evans, PharmD, MBA | Reviewed by Amy B. Gragnolati, PharmD, BCPS
Updated on October 23, 2023
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Key takeaways:

 * The most common type of medication-related insurance rejection providers face
   is a prior authorization (PA). Insurance companies (payers) use PAs to
   increase prescribing of medications on their preferred formulary.

 * “Refill too soon” and out-of-network rejections are also common. A “refill
   too soon” rejection can sometimes be overridden. But, an out-of-network
   rejection requires a prescription to be sent to the patient’s in-network
   pharmacy.

 * Drug utilization review (DUR) rejections are clinical alerts where the payer
   has a clinical concern with the prescription, based on claims data. It’s
   critical for providers to handle these rejections directly.

Andy/iStock via Getty Images
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Insurance rejections are a common part of daily practice for pharmacists and
healthcare providers. Rejections help insurance companies (payers) control
costs. But they can add a significant administrative burden for medical offices.

Understanding insurance rejections can help provider offices improve workflow
and communication. This can also save staff time and ensure people in their care
get the medications they need.

In this article, we’ll look at the most common types of medication-related
insurance rejections and discuss ways providers and pharmacists can handle them.


1. PRIOR AUTHORIZATIONS 

Prior authorizations (PAs) are one of the most common kinds of rejections. A PA
helps payers control cost by increasing use of medications on their preferred
formulary.

The fastest way to handle PAs is to use an electronic PA (e-PA) service. The
e-PA process looks like this:

 * The prescription is sent to the pharmacy, and the pharmacy receives a PA
   rejection from the insurance company.

 * The pharmacy sends a PA request to the provider’s office. This request
   already includes most of the patient’s basic information, including the
   medication being requested.

 * The office staff logs into the e-PA account and completes the request, which
   includes answering clinical questions and sometimes attaching chart notes.

Insurance companies sometimes deny prior authorizations. They often will not
approve a non-formulary product unless:

 * A person has already tried their plan’s preferred products

 * A person has an intolerance or contraindication to the preferred products

 * A provider demonstrates that switching medications is essential to treatment
   success

If your office receives a denial, there are two actions you may be able to take:

 1. Peer-to-peer review: With a peer-to-peer review, a healthcare professional
    working for the insurance company speaks with the provider directly and
    decides if the denial should be overridden. You’ll often need an appointment
    for a peer-to-peer review.

 2. Appeal: An appeal is time-consuming, because it involves writing a letter to
    the insurance company explaining the person’s situation and why they’re
    unable to use products on the formulary.

The letter included with the PA denial will provide contact information for both
appeals and peer-to-peer reviews.

Embedded pharmacists can also help with the PA process. These are pharmacists
who work inside a medical office rather than in a pharmacy.


IN SUMMARY

PAs are a process insurance companies use to control their costs. Medical
offices are responsible for responding to requests and denials. But embedded
pharmacists and technicians, who are becoming more commonplace, can be a great
resource for handling these.


2. REFILL TOO SOON

Each time a prescription is filled, a pharmacy’s staff submits a record to the
insurance company with both the quantity filled and the length of time the
prescription is supposed to last.

Most payers only approve refills when the medication should be getting low, to
prevent them from paying for too much medication. For example, an insurer may
pay for a refill on a 30-day supply of medication only after 23 days have passed
since the last prescription was filled. Filling it before this point can trigger
a “refill too soon” rejection.

Sometimes you can obtain a “refill too soon override” for this rejection. Two
common overrides are:

 * Vacation override: If the person is going on vacation and would run out of
   medication before getting back, they may be able to get a refill early. But
   this is often limited to one or two overrides per year.

 * Medication synchronization: Medication synchronization is an adherence
   service where the pharmacy aligns a person’s refills to be filled on the same
   day each month. The pharmacy has to fill a small quantity of medication to
   align them. Some insurers will pay for medication synchronization. But it’s
   possible for these small fills to initially trigger a “refill too soon”
   rejection.


IN SUMMARY 

“Refill too soon” rejections happen because a person is trying to get their
medication before the payer thinks it’s due. In some cases, the pharmacist can
obtain a “refill too soon override” for these rejections.


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3. OUT-OF-NETWORK

Payers often have preferred pharmacy networks, especially for specialty or
high-cost medications. They may choose one or two in-network mail order
pharmacies for these medications. Insurance changes, which commonly happen at
the beginning of the year or with job changes, can affect a person’s in-network
pharmacies.

If you get an out-of-network pharmacy rejection, you’ll likely need to send the
prescription to an in-network pharmacy.

This is another case in which an embedded pharmacist can help. In some cases, a
pharmacy may be able to transfer the prescription. But, that can be
time-consuming, especially if it requires calling a mail-order pharmacy.


IN SUMMARY

An out-of-network rejection happens when a pharmacy is not in an insurance
company’s preferred network. In this case, the out-of-network pharmacy may need
to transfer the prescription to the in-network pharmacy. The provider may also
need to send a new prescription to that pharmacy.


4. DRUG UTILIZATION REVIEW REJECTIONS

Out of all of the medication-related rejections an office receives, a drug
utilization review (DUR) rejection is the one type the provider should
personally look at. These rejections are clinical alerts from payers, based on
their claims history.

DUR rejections designed to help keep patients safe. They happen when payers
notice medication overuse, interactions, or other safety issues. It’s best for a
provider to address these directly. Office staff shouldn’t be overriding them on
their own.

Examples of DUR rejections include:

 * Prescribing a benzodiazepine with an opioid

 * Prescribing a high dose of an opioid

 * Prescribing a medication for an older adult that can raise the risk of falls

A pharmacist can enter codes to override these rejections. However, some require
the pharmacist to attest to speaking with and getting approval from the
prescriber. The pharmacist will typically call the office about DUR rejections.
But they may override them if they've spoken with a provider about it before.


IN SUMMARY

DUR rejections are clinical warnings insurance companies use to keep patients
safe. Pharmacists override the majority of them, but there are times they may
call the prescriber’s office. In these cases, it’s best for the provider to
directly address the concern. Don’t allow office staff to override DUR
rejections.


THE BOTTOM LINE

There are several types of insurance rejections that can happen at the pharmacy.
But not all rejections can be handled by the pharmacist. Understanding the most
common types of rejections and how to handle them can help you and your staff
save time and ensure your patients receive their medications.


REFERENCES

Academy of Managed Care Pharmacy. (2019). Drug utilization review.

Agency for Healthcare Research and Quality. (2022). United States Health
Information Knowledgebase.

View All References (3)
expand_more

American Medical Association. (2017). Reduce practice burdens with electronic
prior authorization.

American Medical Association. (2023). Prior authorization practice resources.

Robeznieks, A. (2021). How to make peer-to-peer prior authorization talks more
effective. American Medical Association.

GoodRx Health has strict sourcing policies and relies on primary sources such as
medical organizations, governmental agencies, academic institutions, and
peer-reviewed scientific journals. Learn more about how we ensure our content is
accurate, thorough, and unbiased by reading our editorial guidelines.

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