The people's voice of reason
The people's voice of reason
It’s frustrating when your health insurance doesn’t cover your medication. A drug that appears on a formulary — the list of medications covered by a health insurance plan — can get dropped anytime. This can happen if a medication is seldom used, there is a generic or biosimilar available, or a more affordable option exists. Whatever the reason, you’re stuck with the full cost even though you have coverage for prescribed medications.
GoodRx, a platform for medication savings, shares what you can do if your prescription medication isn’t covered.
Key takeaways:
If your insurance plan won’t pay for a new prescription or if your plan stops covering a medication you already take, you can explore the following options.
1. Talk to a healthcare professional about alternatives
A healthcare professional has no obligation to weigh the costs of your medications. They almost certainly won’t know what’s covered by your prescription plan’s formulary. That’s why it’s up to you to raise concerns about your out-of-pocket costs.
If one of your prescriptions has been dropped from coverage or will cost you more, ask your doctor about generics and alternative medications. These include biosimilars for biologics, which may be more affordable.
If you can’t find a more affordable option that works for your condition, a healthcare professional may still be able to help you. You may consider:
2. Ask for an exception from your prescription plan
If a healthcare professional can’t help you find an affordable option, ask your insurer about making a formulary exception that provides coverage for your medication. A physician will most likely need to submit a supporting statement (sometimes called a letter of medical necessity) explaining why the medication is needed and that alternatives would not be as effective or would have a side effect.
It’s important to note that some plans will require step therapy before approving your exception. Step therapy is a type of prior authorization that requires you to:
Even if the medication you need is on your plan’s formulary, it may be in a higher tier. The plan may also consider it nonpreferred. Nonpreferred and higher-tier medications typically cost more out of pocket. In this case, you can ask your plan for a tier exception. If approved, this will help lower your out-of-pocket costs for the medication.
3. Apply for a patient assistance program or manufacturer copay program
Patient assistance programs and manufacturer copay programs help people save on specific medications — particularly costly, brand-name prescriptions that may not be covered by your plan. These programs can reduce out-of-pocket costs to $0 per month for people with and without insurance. Keep in mind: Patient assistance programs generally serve those who are uninsured or underinsured and find their out-of-pocket costs unaffordable. Manufacturer copay programs are typically for people with commercial insurance.
You can usually find these programs on the websites of medication manufacturers. The companies often have partnerships with related company foundations or other nonprofit organizations that connect people in need with deeply discounted or free medication.
Here are some examples of programs that can help you afford your medications:
4. Reconsider your health plan during an enrollment period
If your insurance doesn’t cover your prescription medication, consider switching to a plan that has the drug on its formulary. You can do this during your enrollment period. If you are joining original Medicare or a Medicare Advantage plan, be sure to use the Medicare Plan Finder tool to identify a Medicare Part D prescription drug plan that covers the medications you need.
If you have explored other options for lowering your prescription costs without success, you can try filing an internal appeal with your insurance plan once your claim for coverage is denied or you can request a coverage determination for a drug you haven’t started taking.
The exact process will depend on your plan, but you are typically required to:
If you need help, check whether your state or territory has an active consumer assistance program. If you’re enrolled in Medicare, you can also get free help from a State Health Insurance Assistance Program (SHIP) near you.
If your appeal is for a medication you haven’t started taking, the insurance plan must complete the internal review within 30 days. If it’s for a medication you have started taking, the review must be completed within 60 days. In urgent situations, you can request an expedited appeal. In expedited cases, a final decision must be made as soon as required by your medical condition or within four business days of receiving your request.
If your insurance plan rejects your appeal, try requesting an independent review through your state’s insurance regulator as a last resort. The process can seem daunting, but the odds are in your favor because many appeals get approved.
The independent review can take up to 60 days. If your state doesn’t have an external review process, the U.S. Department of Health and Human Services (HHS) or a private review organization will oversee the case. You won’t be charged anything if HHS handles the review, but it may cost up to $25 through your state or a private review organization. If you urgently need the medication, you can request an external review before the internal appeal is complete.
If you’d like more information on the appeals process, check out these sites:
What is a nonformulary drug?
A nonformulary drug doesn’t appear on your insurance plan’s list of covered medications. This typically happens when there is a generic version available or if your prescription plan prefers a similar medication deemed safer and more effective. A nonformulary drug is not covered, but you can ask for an exception so that your medication is covered.
How do you find out if your insurance covers your medication?
Every health insurance plan with prescription coverage has a formulary, or a list of covered medications. Your plan’s summary of benefits and coverage should explain your expected cost sharing in each tier.
What happens to your prescriptions when your insurance changes?
When your prescription plan changes, your medications may cost you more or less. That’s because what you’re taking may not be covered, may appear in a different tier of coverage, or may have a different copay or coinsurance amount. If your prescription coverage is ending, you may need to prepare to pay for your medications in full or plan to seek assistance from programs that can help you afford your medications.
Don’t panic if your prescription plan won’t pay for your medication. This can happen if your treatment isn’t on your plan’s formulary or if coverage has been denied. But there are steps you can take to reduce out-of-pocket costs for your medication or get a coverage denial reversed.
First, see if there’s a generic or lower-cost medication that will work for you. You may also qualify for a patient assistance or copay assistance program that can reduce your out-of-pocket costs. If neither of these options works, you can ask your insurance plan for an exception to the formulary so that your medication may be covered. You can formally appeal a coverage denial with an internal review. As a last resort, seek an external appeal. Remember that every objection to your insurance company will require a letter of medical necessity from your prescriber.
This story was produced by GoodRx and reviewed and distributed by Stacker.
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