Your IBD Coverage Call Script: 12 Questions to Ask Your Insurer

Calling your insurance company about a biologic or advanced therapy for inflammatory bowel disease is one of those tasks that goes badly when you improvise. Vague questions produce vague answers, and vague answers do not move a prior authorization forward. The delay is not trivial: in a cohort of 190 children starting biologics, prior authorization added a median of 10.2 days to the time between the doctor's recommendation and the first dose, and complicated authorizations requiring appeal, step therapy, or peer-to-peer review added 24.6 days. What follows is a call script of twelve specific questions to ask insurance about biologic coverage, grouped so you can work through them in order and leave the call with facts instead of impressions.

Before You Dial: What to Have in Front of You

Pull your insurance card, the exact drug name and strength your gastroenterologist prescribed, the prescribing clinic's name and phone number, and the National Provider Identifier for your prescriber if you can get it. Have your Summary of Benefits and Coverage open too. That document is the standardized plan summary insurers must give you when you shop, renew, or simply request a copy from the health insurance company, and it settles a surprising number of disputes on its own. Open a blank page for notes. HealthCare.gov specifically advises keeping notes and dates from any phone conversation with your insurance company, including the day, time, name, and title of the person you spoke to, because those notes become evidence if you later appeal. Start the log before question one, not after question twelve.

Questions 1 to 3: Which Benefit Is Paying

Start by establishing the plumbing, because everything else depends on it. Question one: is this drug covered under my medical benefit or my pharmacy benefit? Infused therapies given in a clinic are usually billed medically, while self-injected pens usually run through the pharmacy benefit, and the same molecule can sit on both sides depending on how it is administered. Question two: what type of plan do I have, and is it self-funded by my employer? Self-insured employer plans set their own rules and are not bound by state insurance mandates, a distinction that matters later for copay assistance. Question three: does this drug require preauthorization? Preauthorization is a decision by your plan that a service or drug is medically necessary, and it is not a promise the plan will pay, so confirm both the requirement and what it does not guarantee.

Questions 4 to 6: Prior Authorization Status and Deadlines

Question four: has a prior authorization request been received for this drug, and on what date? Ask for the reference or case number attached to it and read it back. Question five: what is the decision deadline for this request, and does the expedited timeline apply? Under the CMS Interoperability and Prior Authorization final rule, impacted payers including Medicare Advantage and Medicaid managed care plans must send prior authorization decisions within 72 hours for expedited requests and seven calendar days for standard requests, effective January 2026, though that rule excludes prior authorization decisions for drugs. Commercial plans owe you written notice of a preauthorization denial within 15 days, or within 72 hours for urgent care cases. Question six: what specific clinical documentation is still missing? Ask them to name the document, not the category.

Questions 7 to 9: Step Therapy, Specialty Pharmacy, and Site of Service

Question seven: is there a step therapy or formulary requirement I have to satisfy first, and does anything I have already tried count toward it? Step therapy, restricted formularies, and quantity limits are standard utilization management tools plans use to contain specialty drug spending, and prior failures often satisfy them if documented. Question eight: which specialty pharmacy am I required to use, and can my prescription be filled anywhere else? Get the pharmacy's name and phone number in the same breath. Question nine: which sites of service are covered for infusion, and is the hospital outpatient department covered at the same rate as an infusion suite or home infusion? These questions about specialty pharmacy coverage and site of care determine whether you receive one bill or three, and the answer frequently differs from what the clinic assumes.

Questions 10 to 12: What You Will Actually Pay

Question ten: what is my cost share for this drug, as a flat copay or a percentage coinsurance, and against which deductible does it apply? Under Original Medicare Part B, for example, you generally pay 20% of the Medicare-approved amount after the annual Part B deductible, with no yearly out-of-pocket cap unless you have supplemental coverage. Question eleven: what is my out-of-pocket maximum, and how much of it have I met? For commercial coverage, the out-of-pocket limit is the point after which your plan pays 100% of covered in-network benefits, and it excludes premiums and out-of-network care. Question twelve: is my plan enrolled in a copay accumulator, copay maximizer, or alternative funding program? These arrangements stop manufacturer assistance from counting toward your deductible and out-of-pocket maximum, which changes your real cost once the card runs dry.

Closing the Call and Handling a No

Before you hang up, read back the case or reference number, the representative's name and title, the decision deadline, and the single next action with its owner. Ask for the answers in writing or through the member portal message system. If the answer is a denial, the clock starts immediately: you generally have 180 days from the denial notice to file an internal appeal, and then four months from the final internal determination to request an external review, whose decision your insurer is legally required to accept. Medicare enrollees follow a separate process and can appeal a refusal to cover a drug, a payment decision, or a change in what they owe. Persistence pays: in a national survey of pediatric gastroenterology providers, 77% of initial payor denials for IBD biologics were ultimately approved, after a median of 18 days and roughly three hours of administrative work per patient. A written record of each call is what shortens the second denial.