What is dose optimization?
Dose optimization, like other coverage restrictions, is a way for insurance companies to cut costs. If your prescription is written for several pills per day and the medication comes in a strength that has the same daily dose in one pill, your insurer may require you to get the latter.
For example, if you have a prescription where you’ll need to take three 20 mg tablets of a medication daily, and a single 60 mg tablet is available, your insurer might only cover a prescription for the 60 mg tablets.
What kinds of drugs require dose optimizations?
Insurance companies will most likely require dose optimization for medications that treat chronic conditions like high blood pressure, high cholesterol, anxiety, depression, ADHD, diabetes, acid reflux and overactive bladder.
How can I get around a dose optimization?
While dose optimization is cost-saving for the insurer and may even save you time and money, doctors usually prescribe medications to be taken at multiple doses throughout the day for good reason, and changing the routine may not be good for your health.
If your prescription requires a dose optimization, your pharmacy will get a rejection when submitting a claim for it. Your pharmacist will then need to call your doctor to get a new prescription for the strength of medication your insurer prefers.
If your doctor does not want to change your dosage, you will need to work with them to submit a prior authorization to your insurer to get coverage. Read more about prior authorizations here. This whole process can take days—or even weeks.
In case you aren’t able to get prior authorization and you need to pay out of pocket for your medication, don’t forget to shop around. GoodRx helps patients save as much as 80% off of the cash price of most prescriptions.
For more on coverage restrictions and how to get the medications you need:
- Prior Authorization: What To Do When You Can’t Wait for Prescription Coverage
- Prescription Quantity Limits: What To Do When Insurance Plans Limit Coverage
- What is Step Therapy? — How To Get Insurance To Pay for Your “Non-Preferred” Drug
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