Dealing with health problems is stressful. Being denied by your insurance for crucial claims is an additional concern.

Additionally, 18 percent of insured adults reported experiencing denied coverage in 2023. Of those who were denied some prescription drug coverage, nearly half said they simply had none.

Donna Staat is trying her best to stay active and enjoy her 60s. But she said knee pain makes that difficult.

“It was nothing major, but unfortunately right after I had a surgical repair or just an arthroscopy to investigate it, I broke my leg,” Staat said.

This led to arthritis. Her doctor ordered a drug called Zilretta, but she said her insurance refused the prescription.

In the end, she ended up paying for it not once, but twice.

Staat said she and her doctor made several phone calls to her insurance company to no avail. In the end, she ended up paying $1,500 out of pocket for the second treatment.

Dr. Richard Lehman is an orthopedic surgeon who said he spends an exorbitant amount of time fighting insurance companies.

“I think a lot of times the insurance company won’t approve a drug or an injection or more physical therapy,” Lehman said. “And a lot of it is just algorithms, right? It says you’ve had 12 visits or the algorithm tells us you don’t need any more and we’ll just stop approving. And a lot of times what will happen is when you appeal and they understand that this is the process, they will agree.”

Consumer Reports said when you’re denied, see if there’s an option to switch medications.

Ask your provider for an exception: If no alternative medication is suitable, your doctor can submit an exception request to your health plan, showing the medical necessity of his prescription. You can also try step therapy, which first tries lower-cost options for your condition. If these options are not effective, your doctor may require that the initial drug be covered.

“The one thing that’s clear is you have to have your doctor as your advocate,” Lehman said. “If your doctor isn’t willing to go the extra mile, you’re not going to get anywhere.”

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Lehman is located in the state of Missouri, which is one of several states that continues to fund a Consumer Assistance Program designed to represent the consumer and will review your appeal.

There are states that no longer have a program. However, that doesn’t mean you’re out of luck. Each state will point you in the right direction on the internet.

Once you’re pointed in the right direction, ask your provider for help.

“Unfortunately, the squeaky wheel is getting oil. So don’t just walk away. Call your insurance company, express your displeasure and tell them, hey, this is what my doctor recommended or this is what I need, and be an advocate for yourself,” Lehman said.

As for Staat, she’s now ready for her next insurance battle and said she won’t back down this time.

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