Please contact your insurance company directly by phone or through their internet website for an explanation of your prescription benefits.

In some cases, your insurance company may require additional documentation, such as a Prior Authorization Form from your dentist. Most insurance plans that cover medication, including Periostat®, will charge you a copay.

Before going to the Pharmacy to have your prescription filled, you may first want to contact your insurance company to find out if Periostat® is covered, and if not, you should ask your insurance company what additional documentation or other procedures they have in place to cover the cost of your prescription.

What you can do if Periostat® is not covered by your Insurance Company

If your Insurance Prescription Plan does not cover Periostat®, you have the right to appeal to the insurance company for coverage for Periostat®. You can do this by phone, through their internet website, or you can appeal by letter addressed to the Pharmacy Benefits Manager of the Insurance Company. Your appeal request will increase the likelihood that your prescription will be covered. You may also contact the Human Resources Department of the company you work for to assist you in contacting the insurance company in the event that Periostat® is not covered. If you are paying to participate in your Insurance Company’s Prescription Plan, you are entitled to receive the medication that was prescribed by your doctor.

The following are Sample Appeal Letters that you or your dentist may use to appeal to your insurance company for Periostat® coverage:

If you are the patient, click on the icon to open the Patient Sample Appeal Letter –

If you want your dentist to send the appeal letter to the insurance company, click on the icon to open the Dental Professional Sample Appeal Letter (or refer your dentist to this webpage) –

Please note that we cannot contact your insurance company or answer questions about your prescription plan. In addition, CollaGenex does not currently offer a free drug program for individuals without prescription insurance or those who are indigent.




For more information on oral health, visit the American Dental Association Web site.