Jeffrey Wade
Many Americans with health insurance that includes prescription drug coverage still face instances where their insurance plans do not cover a drug they need. This can be due to insurance companies dropping coverage for certain drugs or setting limits on medication reimbursement. When this happens, there are several options to explore. You can ask your doctor about generic medications or alternatives that may be more affordable, request a 90-day prescription to compare costs, or apply for patient assistance programs that can help cover the costs of brand-name drugs. If these options are not viable, you can appeal your insurer's decision or request an exception to have your insurer cover the medication. This typically requires a supporting statement from your doctor explaining the medical necessity of the medication.
| Characteristics | Values |
|---|---|
| If your insurance denies medication coverage | Request an exception to the formulary |
| If your insurance denies your exception request | File an appeal |
| If your insurance denies your appeal | Request an external review |
| If your insurer denies your external review request | File for an independent review through your state's insurance regulator |
| If your insurance doesn't cover your medication | Ask your doctor about generics and alternative medications |
| Use a drug discount card or coupon | |
| Apply for a patient assistance program |
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What You'll Learn
Ask about generic or alternative medications
If your insurance does not cover the cost of your prescription, you can ask your doctor about generic or alternative medications that may be more affordable.
Generic medications contain the same active ingredients as their brand-name counterparts and have the same effects. They are usually more affordable than brand-name medications and are more likely to be covered by insurance. For example, the antidepressant Zoloft also comes in a generic form with the active ingredient sertraline. However, not all brand-name medications have a corresponding generic product.
Alternative medications with different active ingredients or mechanisms of action may also be available. While these alternatives may have different side effects, they could still meet the same health management goals. For instance, medications for diabetes come in different forms and active ingredients, so if your insurance does not cover one, they may cover another.
If you discover that a prescribed medication is not covered or has become more expensive, it is your responsibility to bring this up with your healthcare provider. Your doctor is not obligated to consider costs when prescribing medications and likely does not know which medications are covered under your insurance plan. Therefore, it is important to discuss any concerns about cost and ask about more affordable options.
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Appeal the insurance company's decision
If your insurance company denies coverage for your medication, you have the option to appeal their decision. This is something that you have the right to do. The process will vary depending on your insurer, but it will often require you to work with your doctor or healthcare provider to submit an application or letter of appeal. This letter should explain why you need the medication and that it is medically necessary.
You can use the insurer's forms to file an appeal or contact them with your name, claim number, and health insurance policy number. You should also submit any information you want to be considered, such as a letter from your doctor explaining the medical necessity of the medication. If your appeal is for a medication you haven't started taking yet, the insurer must complete the internal review within 30 days. If it's for a medication you've already been taking, the review must be completed within 60 days. In urgent situations, you can request an expedited appeal, and a final decision must be made within 4 business days.
If your insurance plan denies your appeal, you can file for an independent review through your state's insurance regulator. This can take up to 45 days or two months to process and is typically done through an external review process by the federal Department of Health and Human Services (HHS) or a private review organization. There is usually no cost when HHS handles it, but it may cost up to $25 through a private organization or your state. If you work for a large company that self-funds its insurance, you can also ask the human resources department for assistance with drug coverage.
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File for an independent review
If your insurance company denies your request for coverage or won't cover a medication after you request an exception, you have the option of filing an appeal to their decision. If they deny coverage after an internal appeal, you may request an external review, also known as an independent review. An internal appeal happens after a denial of a prior authorization or formulary exception.
You can use the insurer's forms to file an appeal or contact them with your name, claim number, and health insurance policy number. Your appeal should include a doctor's letter explaining why you need the medication. How much time you have to file an appeal may depend on the type of insurance you have. For example, if your appeal is for a medication you haven't started taking yet, the insurer must complete the internal review within 30 days. If it's for a medication you've already started taking, the review must be completed within 60 days. In urgent situations, you can request an expedited appeal, and a final decision must be made within four business days.
If your insurance plan denies your appeal, you can file for an independent review through your state's insurance regulator, which can take up to two months to process. Independent reviews are typically done through an external review process by the federal Department of Health and Human Services (HHS) or a private review organization. There is usually no cost when HHS handles it, but it may cost up to $25 through a private review organization or your state.
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Compare costs with a 3-month supply
If your insurance doesn't cover your medication, there are several options to explore. Firstly, you can ask your doctor about generic medications or alternative treatments that may be more affordable and covered by your insurance plan. Generic medications have the same active ingredients as their brand-name counterparts but are usually more affordable and more likely to be covered by insurance.
Another option is to compare costs by requesting a 90-day prescription. A 3-month supply may offer better value than filling your prescription monthly. According to a study by PubMed, patients in the US can achieve significant cost savings by filling larger quantities of prescriptions for chronic conditions. The study found that 44% of the prescriptions examined were dispensed as 3-month supplies, resulting in a 29% decrease in out-of-pocket costs and an 18% decrease in total prescription costs compared to 1-month supplies. Eighty per cent of patients achieved some cost savings from a 3-month supply, making it a viable option to consider.
Additionally, you can look into patient assistance programs and manufacturer copay programs, especially for costly brand-name medications. These programs can help reduce out-of-pocket costs, and you can typically find them on the websites of drug manufacturers or through services like GoodRx. Drug discount cards, such as the Optum Perks Discount Card, can also help you save a significant percentage on prescription drugs.
If you're employed by a large company that self-funds its insurance, you can also reach out to the human resources department for assistance with drug coverage. They may be able to provide guidance or alternatives to help with medication costs.
Lastly, if you're unable to find a suitable alternative or reduce costs through the above methods, you can request an exception from your insurer or file an appeal. Your healthcare provider will need to provide a supporting statement explaining the medical necessity of the medication and any adverse effects of alternatives. If your request is denied, you have the option to file an appeal, and your doctor's letter will be crucial in supporting your case.
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Use a drug discount card
If your insurance does not cover the cost of your prescription, you can use a drug discount card to save up to 80% on prescription drugs. Prescription discount cards are available at no cost and can be used at many pharmacies across the U.S. They are not a type of insurance plan but rather an option for individuals who may otherwise be unable to pay for their medications.
GoodRx, for example, offers a free prescription discount card that can be used at over 70,000 U.S. pharmacies. The GoodRx card can be used for discounts on most prescription drugs for every member of your family, including pets. It can be used immediately and has no expiration, fees, or obligations. You can request to have the physical card mailed to you, or you can use the digital coupons available on the GoodRx website or mobile app.
Optum Perks also offers a free discount card that can save you up to 80% on prescription drugs. The Optum Perks card can be used at over 65,000 pharmacies nationwide. You can print, email, or download the card from their website.
It's important to note that prescription discount cards cannot be combined with insurance. Patients who have Medicare, Medicaid, or any other state or federal prescription insurance can only use these cards if they choose not to use their government-sponsored drug plan for their purchase.
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Frequently asked questions
If your insurance company denies medication coverage, you can request an exception to the formulary (a list of covered drugs). Your healthcare provider will most likely need to provide a supporting statement to inform your insurance company that this medication is medically necessary and that alternatives will have an adverse effect. If your request is denied, you can file an appeal.
If your appeal is denied, you can file for an independent review through your state's insurance regulator. This can take up to 45 days and may cost up to $25 through a private review organization or your state.
Yes, you can explore generic medications or other alternative medications that may be more affordable. You may also qualify for patient assistance and manufacturer copay programs that can help you cover costs.
