Haris Ashley
Health insurance coverage for prescription medications is an important topic, as nearly half of Americans take at least one prescription drug per month, and prescription drug spending reached $378 billion in 2021. While Original Medicare does not typically cover prescription drugs, there are exceptions, and Medicare Part B covers a limited number of outpatient prescription drugs under certain conditions. Additionally, Medicare Part D offers a prescription drug plan that covers medications. For those with other types of health insurance, prescription drug coverage can vary, and it's important to understand your plan's formulary, or approved list of medications. If your insurance company does not cover a specific medication, there are steps you can take, such as requesting an exception or appealing the coverage decision. Patient assistance programs and manufacturer copay programs can also help reduce out-of-pocket costs for prescription medications.
| Characteristics | Values |
|---|---|
| If medication is not covered | Ask for an exception or appeal |
| If medication is dropped from coverage | Find a new plan that covers it |
| If you are enrolled in a state-regulated health plan | You or your medical provider can request an exception to get a prescription drug covered |
| If your request is urgent | Your insurer must respond within one day |
| If your health insurer denies your appeal | Request a review by an independent third party |
| If you can’t get a one-time refill | Follow your insurance company’s drug exceptions process |
| If you have explored other options for lowering your prescription costs with no luck | File for Medicare Part D prescription drug plan |
| If you have other coverage | What you pay depends on whether your drug plan covers the drug, and if the hospital is in your plan’s network |
| If you are uninsured or your health plan doesn’t cover prescription drugs | You may be able to get help in other ways, including discount cards, drug company discounts, and patient assistance programs |
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What You'll Learn
Requesting an exception
If your insurance company won't cover your medication, you can request an exception. This is a type of coverage determination that allows you to get a prescribed drug that's not normally covered by your health plan. The process differs depending on the insurance company and the state you're in, but here are some general steps to follow:
Find Out if You're Eligible for an Exception
Before requesting an exception, it's important to understand the criteria. Exception requests are typically granted when a requested drug is deemed medically necessary by a healthcare professional. This could be due to the drug's increased effectiveness compared to other covered drugs, or because other covered drugs have adverse effects on the patient.
Gather the Necessary Documentation
To support your exception request, you will likely need a statement from your doctor or prescriber explaining why the specific medication is medically necessary for you. This statement can be submitted verbally or in writing, but some insurance companies may require a follow-up in writing if the initial statement was verbal. Additionally, you may need to submit any other information or forms required by your insurance plan.
Submit the Exception Request
You or your medical provider can submit the exception request to your insurance company. If you are enrolled in a state-regulated health plan, your insurer must respond within three days unless they need additional information. If the request is urgent, they must respond within one day, and your request is automatically approved if you don't hear back within the specified timeframe.
Understand the Cost-Sharing Amount
If your exception request is approved, your insurer must inform you of the cost-sharing amount. They must also approve refills for this drug as long as you have a valid prescription and the drug remains FDA-approved for treating your condition.
Appeal if Necessary
If your exception request is denied, you have the right to appeal the decision. You can first appeal directly to your insurance company and request an internal review. If this is unsuccessful, you can seek an external review by an independent third party. Each insurance company and state may have specific processes and timelines for appeals, so be sure to review those details.
It's important to remember that insurance companies may stop covering medications if there are generic or less costly alternatives available. Therefore, before requesting an exception, it's worth discussing alternative options with your doctor to find a treatment plan that is both effective and affordable.
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Appealing a coverage decision
If your health insurance company refuses to pay for your prescription medication, you have the right to appeal the decision. Here are some steps to take when appealing a coverage decision:
Step 1: Understand Your Coverage and Options
Review your insurance plan documents and understand the specific medication coverage. Identify if there are any exceptions or limitations on certain medications. You can also contact your insurance company to clarify their policies and procedures regarding medication coverage.
Step 2: Consult with Your Doctor
Discuss the situation with your doctor and explore alternative treatment options that may be covered by your insurance plan. Your doctor can also provide a letter or statement explaining the medical necessity of the medication, which can be crucial support for your appeal.
Step 3: Request an Exception
If your medication is not covered, you or your medical provider can request an exception to have it included. This process may vary depending on your insurance plan and location, but it typically involves submitting a formal request to your insurer. Your doctor will need to provide supporting documentation explaining why the medication is medically necessary for you.
Step 4: Initiate the Appeal Process
If your exception request is denied, you can proceed with the appeal process. Contact your insurance company to understand their specific appeal procedures and deadlines. You usually have the right to an internal appeal, where you request your insurance company to conduct a full and fair review of its decision. If your case is urgent, they must expedite the process.
Step 5: Gather Supporting Documentation
To strengthen your appeal, gather relevant documentation, such as medical records, letters from your doctor, and any other information that supports your case. This can include statements from your prescriber explaining the medical reasons for the exception and the potential impact on your health.
Step 6: Seek External Review
If your internal appeal is unsuccessful, you can proceed to an external review by an independent third party. This step involves taking your appeal to an independent organization or the Office of Medicare Hearings and Appeals (OMHA), depending on the type of insurance you have. They will review the case and make a decision without bias.
It's important to act promptly when initiating the appeal process, as there are often time limits involved. Keep detailed records of all communications and decisions during the process. Remember that you have the right to seek assistance and representation throughout your appeal, and don't hesitate to reach out to relevant organizations for support.
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Medicare Part B
You pay nothing for most preventive services if you get the services from a healthcare provider who accepts the assignment. If you are in a Medicare Advantage Plan or other Medicare plan, your plan may have different rules. However, your plan must give you at least the same coverage as Original Medicare. If you use an insulin pump that is covered under Part B's durable medical equipment benefit or you get your covered insulin through a Medicare Advantage Plan, your cost for a month's supply of Part B-covered insulin for your pump cannot be more than $35. If you have Part B and Medicare Supplement Insurance (Medigap) that pays your Part B coinsurance, your Medigap plan should cover the $35 (or less) cost for insulin.
If you already have Part A, you can add Part B during specific enrollment periods. Most people get Part A for free, but some have to pay a premium for this coverage. To be eligible for premium-free Part A, an individual must be entitled to receive Medicare based on their own earnings or those of a spouse, parent, or child. To receive premium-free Part A, the worker must have a specified number of quarters of coverage and file an application for Social Security or Railroad Retirement Board (RRB) benefits. The exact number of quarters required is dependent on whether the person is filing for Part A based on age, disability, or End-Stage Renal Disease (ESRD).
If you've been covered by an active employer group health plan (either yours or your spouse's) since turning 65, and it ended within the last 8 months, you can enroll in Part B without any penalty. This is considered a "Special Enrollment Period." During this Special Enrollment Period, you can apply any time of the year.
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Discount cards
Prescription discount cards can be used at participating pharmacies to get lower prices on prescription drugs. They are free to use and can be used by every member of your family, including pets. There is no paperwork to complete and no limit on usage. You can get a physical card or use digital coupons. The physical card has codes that don't change, while the digital coupons are always updating to get the best possible price at a specific pharmacy.
GoodRx, for example, offers a Prescription Savings Card that can be used at over 70,000 U.S. pharmacies to get discounts of up to 80% on most prescription drugs. They also offer digital coupons on their website or app, which can sometimes offer better savings. ScriptSave WellRx also offers a prescription discount card that can be used at over 65,000 pharmacies nationwide and provides average savings of 65% and up to 80% or more. SingleCare offers prescription coupons that can save you up to 80% on your prescriptions.
It is important to note that discount cards are not insurance and cannot be used in conjunction with insurance. They are simply a tool to help patients get lower prices on their prescription medications.
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Patient assistance programs
It is important to note that the medicines covered by patient assistance programs can change over time. For example, as of January 24, 2025, individuals with commercial insurance could obtain AIRSUPRA for as low as $0 with the SUPRA Savings Card. Those with government insurance, such as Medicare Part D, had an average out-of-pocket cost of $89 per month, while those with Medicaid had lower costs ranging from $0.99 to $13 per month. Some states even offered lower copays or eliminated them entirely. If an individual with Medicare Part D could not afford AIRSUPRA, they might be eligible for the patient assistance program, AZ&Me.
There are also other patient assistance programs offered by companies like AstraZeneca and TEZSPIRE. AstraZeneca provides copay savings cards and patient assistance programs depending on the type of insurance an individual has. TEZSPIRE offers savings regardless of income for those who qualify, with doses as low as $0 and discounts of up to $100 on in-office administration costs.
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Frequently asked questions
If your insurance company won't cover your medication, you can ask for an exception or appeal the coverage decision. If your request is urgent, your insurer must respond within one day. If you are enrolled in a state-regulated health plan, you can request an exception to get a prescription drug covered.
A health plan's "formulary" is the list of medications that are covered by your insurance. Medications on your plan's "formulary" are usually less expensive for you.
Medicare Part B (Medical Insurance) covers a limited number of outpatient prescription drugs under certain conditions. Part B covers drugs that you wouldn't typically give to yourself, like those you get at a doctor's office or in a hospital outpatient setting.
Medicare Part D is a prescription drug plan that covers the medications you need.
