THE BLOG
11/18/2014 07:17 pm ET Updated Jan 18, 2015

How Can I Get My Insurance Company To Cover My Inhaler?

This weekly Q&A addresses questions from real patients about healthcare costs. Have a question you'd like to see answered? Submit it to AskChristina@nerdwallet.com.

Question:

I have asthma. It's not unusual for me to use my short-acting inhaler several times a day, but my insurance will only cover one Proventil inhaler every 60 days. I feel like I'm sacrificing my health trying to make one inhaler last for two months. I can hardly make it last one but can't afford to buy more outright. What can I do to get more of the medicine I need?

Answer:

Asthma is a relatively common diagnosis, currently affecting 18.7 million adults and 6.8 million children, according to the Centers for Disease Control and Prevention. Without proper treatment, the disorder can be fatal. In other words, the concerns you have about your treatment are valid, and chances are, you're not the only person with this question.

The cost of treating your asthma can range from just a few dollars for a generic version of your short-acting inhaler to hundreds of dollars each month for people who take multiple medications to manage the disease.

While insurance companies often limit refills out of cost and safety concerns, struggling to make your inhaler last for a few months may be more than just an insurance coverage issue, but also a medical issue.

Understand your medication and how it works

Understanding the specifics of your medicine will help you make the best decisions about how to get the best, most affordable treatment.

Your inhaler, Proventil, is a brand-name version of the generic drug albuterol. These inhalers are called beta-agonist bronchodilators; they open the airways and allow you to breathe more comfortably. They temporarily treat the symptoms of your asthma. Other medications, namely oral steroids, treat the asthma itself, working to quell inflammation and stop asthma attacks before they happen.

For medical expertise, my team at NerdWallet Health contacted Dr. Alan Mensch, pulmonologist and senior vice president of medical affairs at Plainview and Syosset Hospital in Long Island, New York. He says inhalers like albuterol (Proventil) may be enough for mild asthma, characterized by one or two flare-ups per week, or exercise-induced asthma. But moderate to severe asthma likely also needs a steroid medication for proper management.

"[For] anything more than mild asthma, you should be taking something to get to the cause of the bronchospasms," not merely to treat the occasional attack, says Mensch.

Generally, a short-acting inhaler will contain approximately 200 puffs or inhalations. Adults can take two puffs every four to six hours as needed, or before exercise for exercise-induced asthma. Again, these inhalers are designed for occasional symptoms, a few times a week, and at this rate should last several months.

Contact your insurance company to discuss the limited refills

The first step to finding a solution is simply to ask. Calling to discuss the restrictions with your health insurance company could resolve your problem altogether, as its staff may have read your prescription wrong or entered it incorrectly in their system. Insurance companies limit coverage of prescription medications for a variety of reasons, but a mistake should not be the reason you're denied coverage.

In addition to listing all approved drugs on what's called its "formulary," the insurance company also determines how much it'll cover both in dosage amounts and frequencies. While specifics vary by plan and carrier, most allow for more than one short-acting inhaler every 60 days.

While you're on the phone with your insurer, ask about its policy on brand-name versus generic inhalers. It could be that your insurance policy puts greater limitations on brand-name drugs like Proventil when generic versions like albuterol are available.

If talking with the insurance company doesn't help or leaves you with even more questions, the next step is visiting with your doctor.

Talk to your doctor about treatment alternatives

If you find the issue can be resolved by having a prescription for generic albuterol, ask your doctor if that change would be medically appropriate. Even if you have to pay out of pocket for the medication, albuterol inhalers are much more affordable than Proventil. This is an easy fix, but not the only thing you'll want to discuss with your physician.

Patients can build a tolerance to short-acting inhalers. If you're using yours daily, you may find that it's becoming less effective with time and continued use. Further, this kind of heavy use of a bronchodilator could indicate the need for an oral steroid.

"If someone is using one inhaler per month, it means their asthma is not in control," explains Mensch, "and albuterol will never get a patient under good control; it will just take care of the symptoms."

Mensch recommends someone in your situation discuss steroid options with their doctor. Because you would be using the albuterol less often if you were on a steroid, the insurance limit could no longer be a problem.

File an appeal if no alternatives are available

If your doctor says the best treatment would allow you to have a new Proventil inhaler more frequently than once every 60 days, you can file an appeal with your insurance company.

Filing an appeal involves gathering documentation from your physician and typically writing a letter to the insurance company. Make sure your paperwork includes all the right dates and details, including any conversations you had with the insurance company employees themselves. You can find any carrier-specific appeal documents on your insurance company's website or by calling them on the phone.

You can also look into financial assistance programs like those offered by the pharmaceutical companies themselves. In the case of Proventil, the drug maker Merck may be able to help.

It can be difficult to navigate a refill limitation or outright denial from an insurance company on your own, but your health shouldn't have to suffer for their policies. Getting to the bottom of their decision and exploring other treatment options can help you manage your asthma without racking up costly medical bills.