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Denial Conversion Allows Commercial Insurance Patients to Receive Preferred, but Non-Formulary Medications, and Discounts Offered by MFG through PrimeRx™

At the start of 2022, as they do every year, health plans nationwide announced changes to their formularies, adding certain new drugs while removing others that had been previously included. According to CoverMyMeds, this annual exercise allows health plans "to make way for new, improved medications, control costs and give patients better treatment options."

While these may be worthy objectives, the formulary changes can have profound effects on patients.

As noted by CoverMyMeds, major plans excluded roughly 100 medications from their formularies during 2022. This includes Express Scripts National Preferred Formulary (32 new exclusions, including five specialty drugs), CVS Caremark Commercial (20 new exclusions), and United Healthcare Commercial (50 drug exclusions, many of which were replaced by generic alternatives).

While patients do have options when a prescribed drug is not on their formulary, namely through the prior authorization or direct appeals processes, such efforts can take time, with no guarantee of a favorable outcome.

Now though, there is a better way. Namely, through Micro Merchant Systems' technology-based Denial Conversion Program, which is a key function of the PrimeRx™ pharmacy technology system. Through the Denial Conversion Program pharmacies provide patients with medications rejected by a payer through reimbursement for the costs from Micro Merchant Systems. Patients leave the pharmacy with their preferred medications, and pharmacies receive real-time notification of the discounted patient copay plus the amount the pharmacy will be reimbursed, in addition to a $2.00 transaction administrative fee. Read More >>

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