I have been prescribed birth control pills for the purpose of controlling extremely heavy bleeding. My doctor specifically noted that on my chart. My insurance company will not pay for birth control pills on our prescription card. If it is deemed medically necessary that I take them for this condition, how can the insurance company refuse to cover them? How do I best go about getting them to pay for them?

Dawn

You may be confusing two aspects of an insurance contract. One is medical necessity. The other aspect is that of coverage provisions. In short, for a claim to be paid, the medical service must be medically necessary and included in your coverage provisions. If the service does not satisfy both tests, the claim may not be paid. In this case, the prescription drug you need may not be covered.
Medical necessity is the determination of a qualified person about a surgery or other major medical service. For example, a doctor might recommend that a patient undergo a hysterectomy. Another doctor, employed as the medical director for an insurance company, may review that recommendation and conclude that the surgery is not medically necessary. Perhaps there is another, less invasive treatment that can achieve the same objective with a lower level of risk and, admittedly, a lower cost. Both considerations are important. If the recommended surgery is performed and causes complications, the patient's health is compromised, and the insurance company ends up paying for services that might not have been necessary in the first place. This harms the patient and increases the cost of insurance for everyone. Rarely are recommended services denied due to an adverse medical necessity determination. The possibility exists, however, to protect the patient's health and other policyholders from escalating premiums.

The other important factor here is coverage provisions. Your insurance coverage includes a specific set of contractual provisions that set limits on the kinds of medical services the insurance company will cover. For example, most insurance plans exclude elective procedures, such as plastic surgery. Other services may also be excluded. When it comes to prescription drug coverage, the insurance carrier limits its financial liability by excluding certain pharmaceuticals or drugs used for certain purposes. At the present time, many insurance contracts exclude prescription contraceptives.

So a procedure (or a drug) might be included in a person's coverage, but if it is not determined to be medically necessary, the carrier will not pay for it. Or, if it is medically necessary but not included in the contract provisions, it is similarly not covered.

In your case, since birth control pills are not included in your prescription drug coverage, medical necessity is not a sufficient argument. The insurance company's refusal to pay for them is not based on a test of medical necessity, but on a test of coverage provisions.

In this case, then, you would have to pay for the prescription yourself. But here is something to think about. A 21- or 28-day supply of name-brand birth control pills may cost $20-25. A generic equivalent costs under $10. Most prescription drug benefits charge a co-pay for generics and name-brand drugs. If your co-pay is $10 for a generic drug, you would pay the same for the prescription whether or not your insurance covers it. Further, prescription drug benefits normally limit you to a 30-day supply at a time. If you pay for the drugs yourself, you can order a larger supply and save even more money.

For starters, check out some of the online prescription sources and see the price on the generic equivalent for your birth control pills, or call your local pharmacy for the price. You may be surprised.