Paul Sanchez
It is not uncommon for an insurer to drop a drug from its formulary, or list of covered drugs. This can happen if a medication is seldom used, there is a generic available, or a more affordable option exists. If your medication has been dropped, you can try generics or other alternatives, and you may qualify for patient assistance and manufacturer copay programs that can help cover costs. You can also ask your insurer for an exception, and if that doesn't work, you can appeal the coverage decision. It is recommended that your doctor make the request to establish the medical need and ensure that key health information is included. If your request is denied, you can file a formal appeal first to the insurance company and, if that fails, to an external review board.
| Characteristics | Values |
|---|---|
| What to do if your medication is dropped by insurance | Ask your pharmacist questions about the denial, then call your insurer to find out why the coverage was denied. |
| How to prevent medication from being dropped by insurance | Review your Summary of Benefits and Coverage, which you can get from your insurance company or using a link in the detailed description of your plan in your Marketplace account. |
| How to fight to get your medication covered by insurance | Request an exception from your insurer, preferably with your doctor making the request to establish medical need. If this is denied, file a formal appeal first to the insurance company and, if that fails, to an external review board. |
| How to find lower-cost options | Ask your doctor about generics and alternative medications that may be more affordable. |
| How to bridge the gap when transitioning between insurance plans | The Consolidated Omnibus Reconciliation Act, or COBRA, allows you to stay on your former employer's health insurance plan until you get new coverage. |
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![Drug coverage under national health insurance : Proceedings of the national conference, October 5-7, 1977 Editors : Milton Silverman and Mia Lydecker. 1978 [Leather Bound]](https://m.media-amazon.com/images/I/61IX47b4r9L._AC_UY218_.jpg)
What You'll Learn
- Ask your doctor about alternative medications that may be covered by your insurance
- Request an exception from your insurer to help cover the cost of a drug that's not on the formulary
- File a formal appeal to your insurance company and, if that fails, to an external review board
- Contact your insurer to find out why your coverage was denied and if there were any mistakes
- If you can't get a one-time refill, follow your insurance company's drug exceptions process
Ask your doctor about alternative medications that may be covered by your insurance
If your insurance company refuses to cover your prescription, you have several options. Firstly, you can ask your doctor about alternative medications that may be covered by your insurance plan. Doctors typically don't know which medicines are covered under your plan's formulary, so it's important to initiate this conversation yourself. If you notice that a medication has been dropped from coverage or has become more expensive, inquire about generics or other alternative medications that may be more affordable. Your doctor may be able to prescribe a higher-dose pill, which can be cut in half to save money. They can also help you request a 90-day prescription to compare costs, as a 3-month supply may offer better value than monthly refills.
It's worth noting that insurance companies may provide a one-time refill for your medication while you discuss next steps with your doctor. This can be helpful to bridge the gap and ensure you have access to your medication while exploring alternative options. If you can't find a lower-cost alternative that suits your condition and budget, your doctor can still provide valuable assistance. They can advocate on your behalf, explaining to the insurance company why a specific medication is medically necessary and why alternatives could have adverse effects. This is often done through a letter of medical necessity, which can be submitted with an exception request or appeal.
Additionally, your doctor can guide you through the process of requesting an exception from your insurer. They can provide detailed information about your medical history and the reasons you need a specific drug. If your request for an exception is denied, you can proceed to file a formal appeal, first to the insurance company and then to an external review board if necessary. Throughout this process, your doctor should remain actively involved, providing the required documentation and supporting your case.
While navigating insurance coverage for your medications, it's crucial to stay informed and proactive. Understand that you have the right to appeal decisions and seek independent reviews. Keep in mind that different health plans cover different medications, and certain plans may offer more affordable options. You can also explore patient assistance programs, manufacturer copay programs, and discounts to help reduce your out-of-pocket expenses. Remember, your doctor is a valuable ally in this process, so don't hesitate to initiate these important conversations about alternative medications and cost considerations.
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Request an exception from your insurer to help cover the cost of a drug that's not on the formulary
If your insurance company drops your prescription drug, you can request an exception from your insurer to help cover the cost of a drug that's not on the formulary. The formulary is the list of drugs that your insurer covers, and it is decided by middleman companies called pharmacy benefit managers (PBMs) that your insurer contracts with.
The first step is to ask your insurer to help cover the cost of a drug that's not on the formulary. It is recommended that your doctor makes the request, to establish the medical need and ensure that key health information—such as your diagnosis, other treatments tried, and why they were stopped—is included. Your doctor will need to send paperwork to your health plan indicating the reason you can't take the preferred medications and why you need this specific drug. In some cases, your doctor may have already been notified by your insurer that a drug was dropped and provided information about how to file an exception request. If your doctor doesn't have this information, they should contact the insurer for details.
If your request for an exception is denied, you can file a formal appeal, first to the insurance company and, if that fails, to an external review board. Your doctor should take the lead in this process, providing even more detailed information about your medical history and why you need this specific drug. You and your doctor can include any medical studies or other documents that establish the need for your requested drug. An appeal made to your insurer can take up to a week for Medicare Part D plans and up to 30 days for an ACA plan or most employer plans.
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File a formal appeal to your insurance company and, if that fails, to an external review board
If your insurance company denies your request for an exception, you can file a formal appeal, first to the insurance company and, if that is not successful, to an external review board. This process is known as an internal appeal, and you may ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must expedite the process.
In both cases, your doctor should take the lead, providing detailed information about your medical history and why you need this specific drug. Dianne Savastano, founder of Healthassist, a company that helps consumers navigate the healthcare system, recommends that you and your doctor include any medical studies or other documents that establish the need for your requested drug. An appeal made to your insurer can take up to a week for Medicare Part D plans and up to 30 days for an ACA plan or most employer plans.
If your internal appeal is denied, you can request an external review of that decision. This is where an independent third party reviews the decision by your health insurance company, based on medical necessity. This independent third party can be an independent doctor or healthcare professional. In some cases, insurance companies may choose to participate in an HHS-administered process or contract with independent review organizations. If your plan does not participate in a state or HHS-administered Federal External Review Process, your health plan must contract with an independent review organization.
Standard external reviews are decided as soon as possible – no later than 45 days after the request was received. Expedited external reviews are decided as soon as possible – no later than 72 hours, or less, depending on the medical urgency of the case, after the request was received. If your health insurance company is using the HHS-Administered Federal External Review Process, there is no charge. However, if your issuer has contracted with an independent review organization, or is using a state external review process, you may be charged a fee of up to $25 per external review.
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Contact your insurer to find out why your coverage was denied and if there were any mistakes
If your health insurance company won't pay for your prescription, it's important to understand why your coverage was denied. There could be various reasons, and getting to the bottom of it can help you navigate the next steps effectively.
Start by asking your pharmacist questions about the denial. They might be able to provide valuable insights and direct you to the right people to address the issue. You can also call your insurer directly to find out why the coverage was denied. Having your plan information on hand will be useful for this step. It's worth noting that the reasons for denial can be complex, so you may need to dig deeper to get the right answer.
Another option is to consult your doctor, who can work with you to establish the medical need for the medication. They can provide key health information, such as your diagnosis, other treatments tried, and why they were stopped. Your doctor can also confirm to your insurance company that the requested medication is appropriate for your condition and that other covered drugs haven't been or won't be as effective. This confirmation can be provided orally or in writing and can strengthen your case for coverage.
In some cases, your doctor may have already been notified by your insurer about the medication being dropped and may have information on how to file an exception request. If your doctor doesn't have this information, they can contact the insurer to gather the necessary details. Additionally, your doctor can advocate for an expedited review if a quicker response is required, typically within 72 hours for Medicare Part D plans.
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If you can't get a one-time refill, follow your insurance company's drug exceptions process
If you can't get a one-time refill, you have the right to follow your insurance company's drug exceptions process. This process allows you to get a prescribed drug that is not typically covered by your health plan. It is important to note that the details of each plan's exceptions process vary, so it is advisable to contact your insurance company directly to understand their specific process.
To initiate the exceptions process, your doctor must confirm to your health plan, either orally or in writing, that the requested drug is medically necessary for your condition. This confirmation should include specific justifications, such as stating that all other drugs covered by the plan have not been or will not be as effective as the drug you are requesting. Additionally, your doctor may need to provide information about your diagnosis, previous treatments, and why they were stopped.
In some cases, your doctor may have already been notified by your insurer that a particular drug was dropped and may have received information about filing an exception request. If your doctor doesn't have this information, they should contact the insurer directly to obtain the necessary details. It is recommended that your doctor requests an expedited review if a quick response is required, typically within 72 hours.
During the exceptions process, your health plan may provide you with access to the requested drug until a final decision is made. If your insurance company denies your exception request, you have the right to file a formal appeal, first to the insurance company and then to an external review board if necessary. For Medicare Part D plans, the appeal process can take up to a week, while for an ACA or employer plan, it can take up to 30 days.
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Frequently asked questions
First, call your insurer to find out why the coverage was denied. Sometimes, there are mistakes or it's a paperwork issue. If your medication is not included in your health insurance plan's list of covered drugs, you can try generics or other alternatives. You can also ask your insurer for an exception, which your doctor should request on your behalf.
An exception is a request for your insurer to help cover the cost of a drug that's not on their formulary or list of approved drugs. To request one, your doctor must contact your insurer and provide information about your diagnosis, other treatments tried, and why they were stopped.
If your request for an exception is denied, you can file a formal appeal first to the insurance company and, if that fails, to an external review board. Your doctor should take the lead in this process, providing detailed information about your medical history and why you need this specific drug.
You can try buying your medication from a different pharmacy, as different health plans allow you to get medications from different places. You can also ask your doctor about alternative medications that may be more affordable or covered by your insurance. If you are unable to find a suitable alternative, you may qualify for patient assistance and manufacturer copay programs that can help cover the costs of your medication.
