What to Do When Patients Panic Over Prior Authorization, Bills, or Denied Medications
A Quick Guide for Patient Advocates Supporting Medicare Beneficiaries
Medication delays, unexpected bills, or denied prescriptions can send patients into crisis These moments often happen without warning and can leave beneficiaries and caregivers confused, frustrated, and scared about losing access to critical treatment
Patients navigating Medicare Part D changes may feel overwhelmed by:
Prior authorization hurdles (“Why is my medication suddenly denied?”)
New or higher copays (“Did something change in my coverage?”)
Denied prescriptions (“My medication isn’t on the plan list anymore what now?”)
With the Inflation Reduction Act reshaping prescription drug coverage, cost caps, and payment schedules, patient fears can escalate quickly.
Advocates are key to easing anxieties and helping patients navigate next steps This guide offers practical strategies to reduce stress, troubleshoot barriers, and connect patients with the right resources at the right time
Response Strategies for Advocates
When Medication is Denied or Delayed (Prior Authorization
Issues):
Pause and gather details: Ask why the medication was denied. Was it for missing paperwork, a formulary restriction, or an alternative drug requirement?
Appeal quickly: Medicare beneficiaries have the right to appeal denials. Start with the plan’s internal appeal and escalate to an Independent Review Entity if needed.
Involve the prescriber: Doctors can provide medical necessity letters, peer-to-peer reviews, or suggest alternative covered medications
Use transition fills: If the denial happens at the start of a new plan year, patients may qualify for a temporary supply while the appeal is underway
When Bills Feel Overwhelming or Confusing:
Request an itemized bill: Break down what is being charged and check for errors.
Ask about financial assistance: Medicare Savings Programs, Extra Help (Low-Income Subsidy), manufacturer patient assistance programs, and nonprofit foundations may cover costs.
Talk to the pharmacy: Sometimes pharmacists can identify lower-cost therapeutic alternatives or generic equivalents
Negotiate or set up payment plans: Hospitals, clinics, and specialty pharmacies often have flexibility if you ask early
When Patients Fear Losing Access
to Medications:
Stay ahead of open enrollment: Review formularies each year.
Document everything: Keep denials and appeal records.
Build a support team: Connect with advocacy groups.
Know your rights: Medicare beneficiaries are entitled to timely reviews.
Smooth the Financial Burden
Out-of-Pocket Cap: Starting January 2025, total spending on covered drugs is capped at $2,000 annually.
Medicare Prescription Payment Plan: Also beginning in 2025, patients can spread prescription costs monthly. Each individual should review the M3P carefully to determine if it is the right choice for them
Connect patients to additional resources for financial help including Extra Help, Medicare Savings Programs, manufacturer assistance, and/or financial assistance organizations
Navigate Coverage Denials:
Appeal promptly: Begin with the plan’s internal appeal → escalate to Medicare’s Independent Review Entity if needed
Engage prescribers: Doctors can submit medical necessity letters, do peer-to-peer reviews, or recommend covered alternatives
Transition fills: If denial occurs at the start of the year, patients may qualify for a temporary supply while appeals are pending
Refer to Advocacy Resources:
Accessia Health and other nonprofits offer case management services to help beneficiaries understand benefits and coverage
Preparing Patients for Open Enrollment (Oct 15 – Dec 7)
Advocates can prevent future panic by guiding patients before troubles start:
Encourage annual plan review: Formularies, copays, and prior authorization rules may change year to year
Compare plans: Use Medicare’s Plan Finder with patients to check medication coverage and costs GetMyMeds is a tool used for opting in to the Medicare Prescription Payment Plan
Identify red flags early: If a drug is moving off formulary or adding prior authorization, help patients prepare alternatives in advance
Communicate proactively: Host Q&A sessions, provide printed checklists, and connect patients to trusted nonprofits for one-on-one help
KEY TAKEAWAY
Patients panic when bills spike or access feels threatened but advocates can de-escalate fear By slowing down the panic, clarifying coverage, smoothing costs, appealing denials, and preparing patients for open enrollment, you transform crisis moments into opportunities for empowerment
Accessia Health, a national charitable patient assistance organization, is dedicated to eliminating healthcare barriers for people with rare or chronic health conditions Comprehensive services include personalized case management, financial assistance, education, and legal aid support Our flexible funding model goes beyond copays, allowing individuals to pay for other essential medical expenses including insurance premiums, screening and diagnostics, therapy services, travel costs, and more We work to ensure that every individual has access to the care they need to lead a healthier life
