If I lack prescription coverage, can my insurance company refuse to cover drugs administered by my doctor?

My wife and I are arguing about whether or not insurance companies will refuse to cover drugs administered in a doctor's office if you do not have prescription coverage. She says that prescriptions and drugs given by a doctor (e.g. anesthetics, steroids, etc.) are two separate things and insurance companies could not refuse to cover the latter based on lack of coverage for the former. I say that insurance companies will do anything to make a buck even if it defies rational explanation. Does anyone know which of us is correct?

1 Answer

  • 1 decade ago
    Favorite Answer

    Prescription drug coverage is for medications filled at retail pharmacies such as Walgreen's, CVS, local supermarkets, ect. For example, if your doctor prescribes you some medication to treat a medical condition such as asthma, and hands you a signed prescription to take to the pharmacy, then you need prescription drug coverage.

    If you have a procedure performed in a doctor's clinic, then the drugs administered are part of the procedure and you don't need prescription drug coverage for this. what you need is health insurance. For example, I had to have an epidural steroid injection for back problems, and this was performed in the pain management doctor's main clinic. My prescription drug coverage was not used in this case, and three drugs were administered; sedative, local anesthetic, and steroid medication. This is considered part of a whole of a medical procedure. My health insurance company received the bill, minus my $30 copay.

    It is not uncommon for a doctor's office to obtain authorization for procedures. Sometimes the insurance company can try to deny coverage if this is not done. Do some of the leg work yourself to be on the safe side, call your insurance company and ask.

    Prescription drug coverage is for the pharmacy. Also, those discount cards you see for generics at all the major chains are not insurance. They are simply discount cards; and the discount is only good for the generic drugs on the list. They may be helpful if you don't have any coverage, but they are not insurance coverage.

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