Hidden deep within your health plan is an important document most people never read.
Your “formulary”—the list of drugs your insurance company covers—determines whether you’ll share the cost of your prescription with your insurance company or you’ll be stuck paying a high price at the counter.
This list can change during the plan year—drugs are removed, new drugs are added, restrictions may be added or removed, and coverage levels may change throughout the year. (Changes are the most likely when it’s re-enrollment time.)
Nobody wants to be stuck paying the full cost of their prescription, so you’ll want to be diligent in checking to make sure your current prescriptions are covered by your plan’s formulary. You can usually find it on your health insurer’s website.
GoodRx sat down with Consumer Reports Best Buy Drugs to answer five common questions about how to make sure your prescriptions are covered—and what to do if they’re not.
GoodRx: What if my prescription drug is dropped entirely by my insurance plan?
Best Buy Drugs: If your drug is no longer covered, first ask your doctor about other drugs on your formulary that may be just as effective and safe for your condition. Most plans will offer one or more alternatives to a medication they no longer cover.
If using an alternative isn’t possible, your doctor can file an exception called a “prior authorization” through your insurer, requesting that the drug be covered because it’s medically necessary. Your plan should approve or deny your request within a few days, and there is usually a mechanism for appeal.
GoodRx: I noticed a new tier on my formulary: non-preferred generic. What does that mean?
BBD: “Tiers” on insurance plan formularies are essentially a way to determine how much you’ll pay out of pocket for your medications. Most plans have about four levels, or tiers, of coverage, but in the last few years, many insurers have added a fifth tier by splitting the “generics” tier into two: One is “preferred” and the other is “nonpreferred.”
Companies do this to encourage you to choose less expensive medications. Your copay for a drug in the non-preferred generic tier, for example, may be $15, compared to a preferred generic in the lowest tier, where your copay could be $5 or less.
GoodRx: How does my deductible affect how my drugs are covered?
BBD: Your deductible is the set amount you need to spend each calendar year before your plan’s benefits kick in. In other words, you’ll pay full price for most services (including prescription medications) until you reach your deductible.
Some plans apply the “general medical” deductible to prescriptions as well, which means that the plan won’t make any payments for your medications until you’ve met your entire medical deductible. Other plans have a (generally) lower deductible that applies specifically to prescription coverage. Check with your insurer’s Summary of Benefits to find out how much you’ll pay out of pocket before your drugs are covered.
GoodRx: If my drug is no longer covered, can I appeal to my insurance plan to have it covered?
BBD: Yes, but it can be a lengthy process. You may have a few options, including the prior authorization route mentioned above. Depending on the medication, some plans may also require that you agree to “step therapy” first, which means trying other treatments before they approve the drug your doctor was going to prescribe. If the other treatments don’t work for you, you can work with your doctor to go through an appeal. You’ll need to fill out a form provided by your insurer or write a letter that include the name of the drug, why you need it covered, and any other supporting documents from your doctor. Your insurer can take up to 60 days to complete the appeal and get back to you.
If your insurance company denies your appeal, you can file for an independent review with your state’s insurance regulator, which will make the final decision. If your state doesn’t have an external review mechanism, the Department of Health and Human Services (HHS) or an independent review organization will oversee the process. This decision can also take up to 60 days. It’s free if handled by the HHS, but may cost you to $25 if it’s handled by your state or an independent review organization.
For more details on the appeals process, go to HealthCare.gov. For tips on how to write and submit an appeal, go to Patient Advocate Foundation (if you’re on Medicare, go to CMS.gov). To find your state regulator’s contact information, visit the National Association of Insurance Commissioners website.
GoodRx: In addition to the savings on GoodRx, what are some other ways to get help paying for my prescriptions?
BBD: Before you start a search for financial assistance, ask your doctor or pharmacist to review everything you’re taking; it could be that some of your medications are no longer needed.
If you’re facing high out-of-pocket costs, consider shopping around for lower prices. GoodRx price comparisons and Consumer Reports’ secret shoppers have found that prescription prices can vary widely from one pharmacy to the next, even in the same zip code.
If you don’t have health insurance or have a plan without drug coverage, look into applying for a patient-assistance program (PAP). PAPs have restrictions based on income, but if you qualify, you could get drugs at a deeply-discounted price, or even for free. For more cost-lowering tips, see Consumer Reports’ advice.
Consumer Reports Best Buy Drugs is a public education project dedicated to helping you talk to your doctor about prescription drugs and helping you find the most effective and safest drugs for the best price.