Jane Dotson
It can be frustrating when your health insurance won't cover your medication. Before your plan covers a particular drug, you may have to show that you meet specific criteria. You can find out if your health insurance plan covers a prescription by calling the number on the back of your insurance card, using an online portal or mobile app, or asking your pharmacist. If your insurance won't cover your medication, you can explore other options, such as generic medications or patient assistance programs. You can also request an exception or appeal the decision.
| Characteristics | Values |
|---|---|
| Prescription coverage | Call the number on the back of your insurance card or check with your pharmacist |
| Prescription look-up tool | Available on HealthCare.gov |
| Cost | If your insurance denies coverage, you may have to pay the full cost |
| Appeal | You can appeal the decision of your insurer if they deny coverage |
| Prior authorization | Requires you to try a less costly medication first |
| Tier exception | If the medication is high-tier or non-preferred, you can ask your insurer for an exception |
| Medicare | Covers a limited number of outpatient prescription drugs under certain conditions |
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What You'll Learn
Prescription look-up tools
HealthCare.gov Prescription Look-up Tool:
This tool is available for residents of states that use the federally-facilitated HealthCare.gov Marketplace. It allows users to search for a specific prescription drug and find out if their health plan covers it on its "formulary," which is a list of covered drugs. Additionally, it provides information on the cost-sharing structure associated with the medication. If a particular drug is not found on the formulary, users can appeal for an exception if their doctor deems it medically necessary.
Network Health's Look-up Tool:
Network Health, a health insurance provider, offers a comprehensive list of covered drugs, also known as a Formulary or Preferred Drug List. Their search tool allows users to find medications covered under their plans, including commonly covered medications, drug tiers, and any restrictions or special requirements. Network Health also provides information on Medicare Advantage Plans and the Medicare formulary. It is important to note that their formulary may change, so users should ensure they are referring to the most up-to-date version.
Aetna's Prescription Drug Plans:
Aetna provides tools and guidance to help members find covered medications and understand their associated costs. Aetna members can log in to their member website to access a list of commonly covered drugs under their specific plans. Additionally, members can refer to their Summary of Benefits and Coverage (SBC) to find their pharmacy plan name. If you are considering an Aetna plan, you can inquire with your employer's HR department for the plan name.
Mobile Apps:
Many insurance companies offer mobile apps that assist users in pricing drugs based on their current insurance plan coverage. These apps provide convenient access to information about covered medications and related costs. Examples of insurance companies with mobile apps include Aetna, UnitedHealthcare, Anthem, and Blue Cross Blue Shield.
Direct Contact:
In addition to using online tools, individuals can directly contact their insurance provider by calling the number on their insurance card or member ID card. By providing their insurance member ID, individuals can inquire about coverage benefits for specific medications. Alternatively, individuals can speak to their pharmacist to determine if a prescription is covered by their insurance plan.
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Appealing for an exception
If your insurance provider denies coverage for a medication, you can appeal for an exception to the plan formulary (a list of covered drugs). You can also request an exception if your medication is on the formulary but is high-tier or non-preferred, as this will cost you more out of pocket.
To request an exception, your prescriber must provide a statement explaining the medical reason why the exception should be approved. You can ask for an expedited (fast) request if you or your prescriber believe that waiting for a standard decision may seriously jeopardize your life, health, or ability to regain maximum function.
If your exception request is denied, you have the right to appeal the decision. The process can seem daunting, but many appeals are approved. The independent review can take up to 60 days. If your state doesn’t have an external review process, the federal Department of Health and Human Services (HHS) or a private review organization will oversee the case. Your review won’t cost anything if HHS handles it, but it may cost $25 through your state or a private review organization. If you urgently need the medication, you can request an external review before the internal review is complete.
You can learn more about the appeals process on HealthCare.gov, which provides information on navigating the appeals process. The Patient Advocate Foundation has tips on how to write and submit an appeal, and the Centers for Medicare & Medicaid Services has tips on how to write and submit an appeal for Medicare plans.
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Prior authorisations
Prior authorization is a process that insurance companies use to control costs. It is required by insurance companies for some medications, including those that may have less expensive alternatives. This process usually takes about 2 days, and once approved, the prior authorization is valid for a defined period. If you can't wait for approval, you may be able to pay upfront at the pharmacy and submit a reimbursement claim after approval.
Prior authorization is handled by your healthcare professional's office. If your prescription requires prior authorization, the pharmacy will notify your healthcare provider, who will then give the necessary information to your insurance company. Your insurer will then decide whether or not to cover your medicine.
Prior authorizations are often required for brand-name drugs with generic alternatives available, drugs intended for specific age groups or conditions, drugs used for cosmetic reasons, and drugs that are neither preventative nor used to treat life-threatening conditions. Additionally, drugs with higher-than-standard doses that may have adverse health effects, dangerous interactions, or risks for abuse or misuse may require prior authorization.
If your medication is not covered by your insurance, you have several options. You can explore alternative medications, including generics, that may be covered. You can also appeal for an exception to your plan's formulary (a list of covered drugs) if your doctor deems the medication to be medically necessary. If your insurer denies your exception request, you have the right to appeal the decision.
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Medicare appeals
If your insurance provider decides to stop covering a medication you are taking, or refuses to pay for a new prescription, you may be able to appeal the decision. The appeals process varies depending on the type of coverage you have, but there are generally five levels of appeals. If you disagree with the decision made at any level of the process, you can usually go to the next level.
If your state uses HealthCare.gov, you can use a prescription look-up tool to see if your health plan covers a prescription drug on its "formulary" (a list of covered drugs). If your drug is not on the formulary but your doctor says it is medically necessary, you can appeal for an exception to the plan formulary. If the exception is granted, your health plan will cover the drug and you will be charged the copay amount associated with the highest tier of your drug plan. If your insurer denies your exception request, you have the right to appeal the decision.
You can also request a \"tier exception\" if the medication you need is on your plan's formulary but is high-tier or non-preferred, which will help lower your out-of-pocket costs. Patient assistance and manufacturer copay programs can also help people save on specific medications, particularly costly, brand-name ones that are often not covered by insurance.
If you need help with your appeal, you can get free, personalized health insurance counselling from the State Health Insurance Assistance Program (SHIP). You can also appoint a trusted family member or friend as your representative to help with your complaint.
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Patient assistance programs
There are several patient assistance programs offered by different organizations. For example, people with Medicare Part D coverage can look into the AZ&Me patient assistance program. If you have commercial or private insurance, the TEZSPIRE Together Co-Pay Program may be able to help you save money on your medications, regardless of your income. This program offers doses for as little as $0 and provides discounts of up to $100 on in-office administration costs. Similarly, the TEZSPIRE Together Program offers TEZSPIRE at no cost to those with government insurance if they meet certain qualifications.
Boehringer Ingelheim has a patient assistance program that caps the cost of their inhalers at $35 for people with commercial or private insurance. AstraZeneca US Patient Support also offers savings on their medicines through copay savings cards and patient assistance programs. They have capped the cost of their inhalers at $35 for those with commercial or private insurance. For those with employer-provided or individual private (commercial) insurance, the SUPRA Savings Card can provide AIRSUPRA for as low as $0.
To find out if you are eligible for any patient assistance programs, you can start by contacting your insurance provider. They can provide information about the coverage benefits for specific medications and may be able to direct you to relevant patient assistance programs. Additionally, you can look into programs offered by the manufacturers of the medications you need. These programs are often designed to help people afford their brand-name medications, which are typically more expensive and may not be covered by insurance. Remember that patient assistance programs are generally for the uninsured, while manufacturer copay programs are typically for those with insurance.
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Frequently asked questions
Yes, your medication history will show up on your insurance records. Large databases of prescription histories are used by major insurance companies, with data aggregated from sources like health insurers, pharmacies, and medical service providers.
You can request a copy of your consumer report from a consumer reporting agency that specializes in medical records or payments. You can also request this information from the insurance company directly.
It is not recommended to omit certain medications from your insurance application as insurance companies will use your prescription history to assess your overall health and price your policy.
Typically, an insurance company will only need to view records of treatment received for injuries in question. However, it is not uncommon for adjusters to try to access your past medical records to determine the value of the claim and find reasons to deny your claim.
