Benefits Verification Checklist for Arthritis Medications

Getting access to your prescription medications is critical to managing your arthritis. Depending on your health plan, there are important steps you’ll need to take to ensure you get the drugs you need in a timely manner. Use this checklist as a guide to help you prepare.

• Check Your Formulary: Review the list of approved medications in your benefits booklet or on your insurer’s website.  If your medications aren’t included, talk to your doctor right away. It may be necessary to work together to file an appeal so you can get access to the drug.
• Check Your Requirements: Review your health plan’s summary of benefits carefully. It will outline the policies that affect the drugs you use e.g. step therapy or prior authorization requirements. Then you should follow up with your doctor’s office as soon as possible to start the paperwork or online submission process.
• Check Your Out-of-pocket Cost Obligation: Your summary of benefits will outline how much you need to pay for your medications. It will confirm if you need to pay a co-pay or co-insurance amount, and whether you must satisfy a deductible before your insurer begins to pay their portion of the cost. It’s important to know that some plans have a health plan deductible for medical care and a separate medication deductible. If this information is not available on your summary of benefits or you have questions, contact your insurer.
• Check Your Pharmacy Requirement: Your health plan may require you to use a specific pharmacy or receive your medications by mail. This information should be included in your summary of benefits.

In some cases, you may need to complete an online benefits verification form on your insurer’s website. In other cases, it’s the responsibility of your doctor’s office to submit the form. If you have changed insurance plans, medications or doctors, you can use this sample letter to get the doctor’s office to begin the process as soon as possible. Many pharmaceutical companies provide benefit verification assistance for their medications. You should contact their customer service department.