Annually and throughout the year, insurance plans determine which medications to cover and which to exclude. The covered medications are part of a list called a formulary.
Some medications are removed from the formulary when a less expensive option, such as a generic or similar medication, becomes available.
Several alternative options may be available if your insurance plan does not cover your medication.
It may be a shock to learn your insurance plan isn’t going to cover your medication. This sometimes happens when insurance plans drop a drug from their formulary—a list of brand and generic medicines they cover. Insurance plans drop medications for various reasons. Often, there’s a cheaper generic option they prefer you take.
This article reviews steps to take if your medication isn’t covered by insurance. Learn why this happens and how to talk to your insurance company and doctor to find a helpful solution.
Your Medication Isn’t Covered By Insurance, Now What?
You may have just learned your insurance will not cover a medication you’ve taken for years. Or maybe your medical provider wrote a new prescription your insurance won’t cover. Though frustrating, many people encounter this situation at some point during the year.
Plans on the health insurance marketplace are required to provide a list of all prescription medications they cover. Small employers must also provide this information in their health plans. Larger employers fall under different requirements. However, most commercial health plans offer prescription medication coverage. Unfortunately, even if a plan covers prescription medications, some medications may not be covered.
Each health plan has a list of brand-name and generic prescription drugs they cover. This list is called a formulary, which uses a tier system. Medications in the lowest tier are typically generic and cost less. Top-tier medications are usually brand-name medications your plan may help cover—but many top-tier options also come with a high out-of-pocket cost.
Each year, and at times throughout the year, a health plan may choose to no longer cover certain prescription medications based on several factors, including:
- Cost of the medication
- Clinical data for using the medication to treat a specific condition
- The availability of generic options
- Other medications available that may offer similar results
Ask Why the Drug Isn’t Covered
Before taking action, you should understand why your medication isn’t covered. Your pharmacist can generally tell you why insurance doesn’t approve the medication and if there are covered alternatives.
You should also ask your provider why they prescribed this particular drug. There may be a less expensive generic option or another treatment you can explore with your medical team.
You may find that your insurance requires prior authorization—a form your healthcare provider fills out explaining why you need that medication. With the proper paperwork, your prescription may receive approval for coverage. Or you may discover the medication falls outside the guidelines of your plan.
Ask for an Exception From Your Insurer
If your insurance denies medication coverage, you can request an exception to the formulary. Your healthcare provider will most likely need to provide a supporting statement—a way to inform your insurance this medication is medically necessary and that alternatives will have an adverse effect.
Some plans require you to try an alternative medication before they grant a request for an exception. This is known as “step therapy.” If the alternative drug is unsuccessful, your provider can complete the paperwork to get the original medication approved.
Make Your Case to Your Insurer
If your insurance denies your exception request, you can file an appeal. This process varies depending on your insurer. It typically involves working with your medical provider to submit a letter of appeal or application.
People employed by large companies who self-fund their insurance can ask the human resources department for assistance with drug coverage. This is another option that sometimes works in your favor.
If your insurer denies your appeal, you can file for an independent review through your state’s insurance regulator. While this takes extra effort, many requests get approval—so it might be worth your time.
Independent reviews can take up to 45 days. They are typically done through an external review process by the federal Department of Health and Human Services (HHS) or a private review organization. There is usually no cost when HHS handles it, but it may cost up to $25 through a private review organization or your state.
Talk to Your Doctor About Alternatives
Your medical provider doesn’t know which medications your plan covers, and it’s not their responsibility to know. If you discover a prescribed medication isn’t covered or is becoming more expensive, it’s your responsibility to bring this to your healthcare provider’s attention. In most cases, there are alternative options that work just as effectively.
For example, many brand-name medications also have a generic form which is less expensive and covered under insurance. Other ways to save money include:
- Getting a higher dose of the prescription and cutting it in half
- Getting a 90-day supply of the medication
- Asking for free samples
Apply for Patient Assistance Programs and Discounts
Patient assistance programs and discounts help many people cover the cost of their medications based on need. Manufacturing co-pay programs typically help people with insurance, while patient assistance programs generally assist people without insurance.
Check the manufacturer’s website to find out if your medication qualifies for a program. You can also do a google search of your medication and look for coupons. Several online pharmacies also offer coupons or savings cards. SingleCare and GoodRx are two of the more popular discount card sites.
Re-Evaluate Your Coverage During the Next Enrollment Period
As a rule, shopping around on the health insurance marketplace during the open enrollment period is a good idea. Check to see if your previous plan will continue to cover your prescription medications and, if not, which plans will. If you are enrolling in Medicare, use their Plan Finder to find the best plan for your needs.
Try Virtual Options Like K Health
Did you know you can get affordable virtual care with K Health?
Check your symptoms, explore conditions and treatments, and if needed, text with a healthcare provider in minutes. K Health providers can send necessary prescriptions to your local pharmacy. While prescription coverage depends on your health plan, our providers can offer generic options to help keep costs low.
K Health’s AI-powered app is based on 20 years of clinical data.
Frequently Asked Questions
K Health has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. We avoid using tertiary references.
Appealing a health plan decision. (N.D.)
Know your rights in the health insurance marketplace. (2022.)
Medicare prescription drug appeals & grievances. (N.D.)
Things to include in your appeal letter. (N.D.)