Jane Dotson
It can be frustrating when your insurance company doesn't cover a prescribed medication. This may happen when a cheaper generic option becomes available, or when a medication is seldom used. If your insurance plan doesn't cover your medication, you can ask your doctor about alternative medications with the same effects, or request an exception from your insurer. If your request is denied, you can appeal the decision and have it reviewed by an independent third party. You may also be able to reduce your out-of-pocket costs by using prescription discount cards or drug coupons.
| Characteristics | Values |
|---|---|
| If insurance doesn't cover medication | Ask for a one-time refill, appeal the decision, request an exception, or switch to a generic or lower-cost medication |
| Appeal process | Contact the insurance company, submit necessary documentation, and request an independent review if necessary |
| Alternative options | Patient assistance programs, manufacturer copay programs, prescription discount cards, drug coupons, and Rx4Miracles savings coupons |
| Formulary | A list of drugs covered by the insurance plan, including both brand-name and generic medications |
| Step therapy/fail-first | A process where insurers require patients to try less expensive or alternative treatments before covering more expensive medications |
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What You'll Learn
Request an exception to the formulary
If your insurance company doesn't cover your medication, you can request an exception to the formulary. A formulary is a list of brand-name and generic prescription drugs covered by your health plan. Each plan has its own formulary, and medications are often removed from the list when a less expensive option becomes available.
To request a formulary exception, you must submit a Coverage Determination Request form. You can usually find these on the Customer Forms page of your insurance company's website. You will also need a supporting statement from your doctor or prescriber, confirming that the requested medication is medically necessary for your condition. This statement can be submitted verbally or in writing. If submitted verbally, a follow-up in writing may be required.
Once you have the supporting statement, you can submit it along with the Coverage Determination Request form. You can mail or fax these documents to your insurance company. The insurance company must respond within 72 hours of receiving the request. If your request is urgent, you can ask for an expedited decision. If your health depends on receiving the medication quickly, the insurance company must respond within 24 hours.
If your request for a formulary exception is denied, you can appeal the decision. You can request an independent review through your state's insurance regulator, which can take up to 45 days. Many requests get approval, so it may be worth your time.
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Appeal the coverage decision
If your insurance company denies coverage for your medication, you have the right to appeal the decision. The appeals process can be daunting and time-consuming, but it can be very successful, with more than 50% of appeals of denials for coverage being approved.
The first step in the appeals process is to understand why your claim was denied. Your insurer is required to notify you of the denial and explain why it occurred. This explanation is usually provided in a document called an Explanation of Benefits (EOB).
Once you understand the reason for the denial, you can begin the appeals process, which typically has three levels:
- First-Level Appeal: You or your doctor contact your insurance company and request that they reconsider the denial. Your doctor may also request to speak with the medical reviewer of the insurance plan as part of a "peer-to-peer insurance review" to challenge the decision. The purpose of this level is to prove that your medication meets the insurance guidelines and was incorrectly rejected.
- Second-Level Appeal: At this level, the appeal is typically reviewed by a medical director at your insurance company who was not involved in the original claim decision. The goal is to prove that the request should be accepted within the coverage guidelines.
- Independent External Review: If the internal appeal is not possible or unsuccessful, an external review can be requested. In this case, an independent reviewer with the insurance company and a doctor with the same specialty as your doctor will assess your appeal to determine if they will approve or deny coverage. This level removes the final decision-making power from the insurance company.
If your insurer denies your appeal, you can still take further action. You can file for an independent review through your state's insurance regulator, which can be done through the federal Department of Health and Human Services (HHS) or a private review organization. While this process can take up to 45 days and may incur a small cost, many requests get approval.
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Seek a patient assistance program
If your insurance company does not cover your medication, you may qualify for a patient assistance program (PAPs) to help you afford your prescription. PAPs are usually sponsored by pharmaceutical manufacturers and are promoted as a safety net for those without health insurance or those who are underinsured. These programs are also managed by nonprofits and government agencies.
Patient assistance programs can cover the full cost of medications or provide a discount. They often have different requirements and benefits, and each program sets its qualification standards. Generally, you must be a permanent, legal resident of the U.S. or Puerto Rico and prove that you are uninsured or that your insurance does not cover your medication. Most programs also require your healthcare provider to fill out a form.
You can find patient assistance programs on the websites of drug manufacturers or through GoodRx. Some pharmaceutical companies that offer patient assistance programs include AstraZeneca US Patient Support, Boehringer Ingelheim, and Genentech.
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Ask for a generic or lower-cost medication
If your insurance does not cover your medication, it is important to understand why. Your pharmacist can generally tell you why your insurance does not approve of the medication and if there are any covered alternatives.
If you are unable to find a suitable alternative, you can ask your doctor about generic or lower-cost medications that may be more affordable. Generics have the same active ingredients as their brand-name counterparts and have met the Food and Drug Administration (FDA) safety standards. They are usually more affordable than brand names, and your insurance is more likely to cover them. However, not all brand-name medications have a corresponding generic product.
If you are employed by a large company that self-funds its insurance, you can ask the human resources department for assistance with drug coverage. Many drug manufacturers also offer assistance based on need, especially if there is no substitute for an on-patent brand-name drug that you cannot afford. You can search for manufacturers' patient assistance programs by looking up your drug or visiting the pharmaceutical company's website.
If you are unable to find a lower-cost option that works for your condition and your budget, your doctor may still be able to help you. You can try requesting a 90-day prescription and comparing costs, as a 3-month supply may be a better value than filling monthly. You can also ask about getting a prescription for a higher-dose pill and check with your doctor and pharmacist if the medication will work if you cut a pill or dose in half to save money.
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Contact your HR department
If your insurance doesn't cover a medication prescribed to you, it's important to remember that you're not alone, and there are steps you can take to address the issue. One important resource you can turn to is your HR department. Here's what you can do:
Start by gathering information about your insurance plan and the medication in question. Understand the specifics of your insurance coverage, including any exclusions or limitations, and gather details about the medication, such as its medical necessity and any alternative treatments available.
Once you have this information, set up a meeting with your HR representative. They are there to support you and help navigate issues related to your benefits. During the meeting, explain your situation clearly and ask about potential solutions. For example, find out if there are any procedures to request an exception or appeal the insurance company's decision. Your HR department may also be able to assist you in exploring alternative options for coverage or finding ways to reduce the cost of the medication.
If your HR department offers an Employee Assistance Program (EAP), be sure to utilize this resource as well. EAPs often provide confidential support and can offer additional guidance on managing medication costs, dealing with insurance-related stress, or connecting you with financial planning resources. They may also have information about prescription discount programs or other cost-saving measures that could be beneficial to you.
Remember that your HR department is there to support you and ensure you get the most out of your benefits. Don't hesitate to follow up if you need further assistance or if your situation changes. They can provide valuable guidance and help you explore all available options to ensure you receive the necessary treatment.
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Frequently asked questions
First, see if there is a generic or lower-cost medication that will work for you. If you are unable to find an alternative, you can ask your insurance company for an exception to the formulary so that your medication will be covered. If this doesn't work, you can appeal the coverage decision. If your insurer denies your appeal, you can file for an independent review through your state's insurance regulator.
A formulary is a list of drugs covered under your pharmacy benefits. Pharmacy benefit managers decide what is on the formulary, usually choosing the least expensive medications.
The antidepressant Zoloft also comes in generic form as its active ingredient, sertraline.
An exception is when your insurance company agrees to cover a medication that is not typically covered by your health plan. To request an exception, your healthcare provider will most likely need to provide a supporting statement explaining why the medication is medically necessary and that alternatives will have an adverse effect.
An appeal is when an independent third party reviews the case and makes a decision. To request an appeal, you can call your insurance company or visit their website to find out the process.
