Alyssa Lane
It can be frustrating when your health insurance declines to cover the cost of your medication. This can happen for a variety of reasons, including the availability of cheaper generic options, or a medication being seldom used. Fortunately, there are several options to reduce out-of-pocket costs and get the decision reversed. Firstly, it is important to understand why the coverage is being denied. You can do this by asking your pharmacist or calling your insurer. If there is a cheaper alternative, your doctor may be able to prescribe this instead. If not, you can request an exception to the formulary, which will require a supporting statement from your healthcare provider. If this is unsuccessful, you can appeal the decision through your employer or the insurance company.
| Characteristics | Values |
|---|---|
| First course of action | 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. |
| What to do if your medication is not on the formulary | Ask your doctor about alternative medications that may be more affordable. |
| What to do if your medication is on the formulary but still denied coverage | The plan might require prior authorization for the drug. Your healthcare provider will most likely need to provide a supporting statement—a way to inform your insurance that the medication is medically necessary and that alternatives will have an adverse effect. |
| What to do if your insurance company still denies coverage | You can request an exception to the formulary. |
| What to do if your exception request is denied | File an appeal. |
| What to do if your appeal is denied | File for an independent review through your state’s insurance regulator. |
| Other options | Patient assistance and manufacturer copay programs help people save on specific medications. |
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What You'll Learn
Understand why your medication isn't covered
If your insurance declines to cover your medication, the first step is to understand why your medication isn't covered. This can happen with a new prescription or a drug you've been taking for years. Drug plans can change their formularies, or their list of covered drugs, at any time.
Your pharmacist can generally tell you why your insurance doesn't approve the medication and if there are any 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.
Insurers often require prior authorization before approving coverage for more expensive medications. This is a form your healthcare provider fills out explaining why you need that medication. If your insurance requires prior authorization, ensure that your provider has submitted the proper paperwork.
If your medication is not on the formulary, you can request an exception to the formulary. Your healthcare provider will most likely need to provide a supporting statement to inform your insurance that the 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."
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Ask about cheaper alternatives
If your insurance declines to cover the cost of your medication, don't panic. There are several steps you can take to reduce your out-of-pocket costs and explore cheaper alternatives.
First, understand why your medication isn't covered. Your pharmacist can generally explain why insurance doesn't approve the medication and advise on any covered alternatives. You should also ask your doctor why they prescribed this particular drug and if there are any generic or alternative medications that may be more affordable. Your doctor may be able to prescribe a lower-cost generic drug, or they may be able to point you towards programs that can help.
If your insurance plan has dropped your medication from its formulary (its list of brand-name and generic medicines that they cover), it may be because a less expensive generic option is available. You can ask your insurer for an exception to the formulary, which will require a supporting statement from your doctor explaining that the drug is medically necessary and that alternatives will have an adverse effect. If this doesn't work, you can appeal the coverage decision through your employer or the insurance company.
There are also patient assistance and manufacturer copay programs that can help you cover the costs of your medication. These programs can be found on the websites of drug manufacturers or through organisations like GoodRx. Patient assistance programs generally serve the uninsured, while manufacturer copay programs are for those with insurance.
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Appeal the decision
If your insurance company denies coverage for your medication, you can appeal the decision. This is what you can do:
Understand the reason for denial
First, find out why your medication is not covered. Your pharmacist can generally tell you why insurance doesn't approve the medication. It could be that the drug isn't on your health plan's formulary, or list of covered drugs. Sometimes, there are mistakes, or it's a paperwork issue. Your insurer may require prior authorization, or a form filled out by your healthcare provider explaining why you need that medication.
Request an exception
If your medication is not on the formulary, you can request an exception to the formulary. Your healthcare provider will most likely need to provide a supporting statement, explaining that the medication is medically necessary and that alternatives will have an adverse effect. Some plans may require you to try an alternative medication first, which is known as "step therapy". If the alternative drug is unsuccessful, your provider can complete the paperwork to get the original medication approved.
File an appeal
If your exception request is denied, you can file an appeal. This process varies depending on your insurer, but it typically involves working with your medical provider to submit a letter of appeal or application. If you have Medicare, visit CMS.gov for help. If your insurer denies your appeal, you can file for an independent review through your state's insurance regulator.
Seek assistance
Drug companies often offer patient assistance programs to help with medication costs, especially for costly, brand-name drugs. These programs can reduce out-of-pocket costs to $0 per month for people with and without insurance. You can usually find these programs on the websites of the drug manufacturers or through organisations focusing on specific diseases.
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Seek patient assistance programs
If your insurance declines to cover your medication, you can consider seeking assistance from patient assistance programs (PAPs). PAPs are usually sponsored by pharmaceutical manufacturers and promoted as a safety net for those without health insurance or those who are underinsured. They are also offered by nonprofits and government agencies. PAPs can help cover the full cost of medications or provide a discount.
To find out if there is a PAP available for your medication, you can search your medication on GoodRx and look under "Savings Tips", or Google your medication's name along with "assistance program" or "savings program". You can also call your medication's manufacturer and ask if they have an assistance program. GoodRx also has its own GoodRx Helps Medication Assistance Program, which provides free medications through community and charitable clinics across the US.
Some pharmaceutical companies that offer PAPs include:
- Pfizer RxPathways
- Novartis Pharmaceuticals
- NovoCare
- PAN Foundation
- Lilly Cares Foundation
- GSK for You
- Healthwell Foundation
To sign up for a PAP, you may need to call the program or register online. You will likely need to submit tax documents and proof of residence, and your healthcare provider may need to fill out a form. Some programs may also require proof of income and that you meet income guidelines. Once enrolled, there may be limits on how much medication you can receive or how long the program lasts.
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Request a formulary exception
If your insurance declines to cover your medication, you can request a formulary exception. A formulary is a list of drugs, both generic and brand name, that your health plan will cover. If your medication is not on this list, your insurance company may deny coverage. However, you can request an exception to the formulary, which means asking your insurance company to cover the medication even though it is not on their formulary.
To request a formulary exception, you will need to provide supporting information to your insurance company. This may include a letter from your doctor explaining that the medication is medically necessary and that alternative medications will have an adverse effect or are not suitable for you. Your doctor may need to provide more complete information about your medical conditions and why this particular medication is required. Your pharmacist may also be able to provide information about why the medication is necessary.
It is important to understand why your medication is not covered in the first place. There could be a cheaper generic option available, or a different treatment you can explore. Your insurance company may require prior authorization for the medication, which means your healthcare provider will need to fill out paperwork explaining why you need that specific medication.
Some insurance plans may require you to try an alternative medication before they grant a request for an exception. This is known as "step therapy" or "fail first". If the alternative medication is unsuccessful, your provider can then complete the paperwork to get the original medication approved.
If your insurance company denies your exception request, you still have options. You can file an appeal or request an internal or external review. You can also look into patient assistance programs offered by drug manufacturers, which can help reduce out-of-pocket costs.
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Frequently asked questions
First, you need to understand why the coverage is being denied. You can do this by asking your pharmacist or calling your insurer. If you think there has been a mistake, you can request an exception to the formulary (the list of drugs that your health plan will cover). If this doesn't work, you can appeal the decision through your employer or the insurance company.
There are several reasons why your insurance might decline to cover your medication. It could be that the drug isn't on your health plan's formulary, or that the plan requires prior authorization for the drug. The drug might also be on the formulary, but the plan still denies coverage, for example, if they require you to try a less expensive drug first.
A formulary is a list of drugs, both generic and brand-name, that your health plan will cover. Each health plan has its own formulary, which uses a tier system. Medications in the lowest tier are typically generic and cost less, while top-tier medications are usually brand-name and come with higher out-of-pocket costs.
Step therapy, also known as "fail first," is a process in which insurers require the patient to try and fail a less expensive or generic medication before approving coverage for a more expensive medication. This can be dangerous and time-consuming, as the patient's condition may not improve or may even worsen while they are taking the less effective medication.
Yes, patient assistance and manufacturer copay programs can help reduce out-of-pocket costs for medication, especially costly brand-name drugs. These programs are often offered by drug companies whose drugs are routinely turned down by insurance companies. You can typically find these programs on the websites of the drug manufacturers or through organizations like GoodRx.
