What Should I Do If My Drug isn’t Covered by My Insurance? 4 Tips and Tactics

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Tori Marsh
Tori Marsh, MPH, is on the Research Team at GoodRx, and is the resident expert on drug pricing and savings.
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Viagra, Symbicort, Plavix — these are some of the drugs that insurance companies stopped paying for this year, leaving many people on the hook to shoulder the full price of often expensive medications. Why? Drugs are dropped from a formulary — as the list of medications covered by an insurance plan is called — if they’re seldom used or if there are generic or more affordable options available.

To get around these formulary changes and save on your next prescription, consider the following GoodRx-approved tips.

Talk to Your Doctor about Alternatives

Your doctor has no obligation to weigh costs when prescribing your drugs and almost certainly won’t know which medicines are covered under your specific formulary, so it’s up to you to bring up questions about cost. If you notice that one of your medications has been dropped from coverage or has gotten more expensive, ask your doctor about alternative medications that may be more affordable.

If you can’t find a good alternative, your doctor may still be able to help you. Some tricks include: getting a prescription for a higher-dose pill, which you can cut half to save on cost, filling a 90-day supply, which can be cheaper than a 30-day supply, or getting free samples.

Ask for an Exception from Your Insurer

If you and your doctor can’t find an affordable option together, speak with your insurer about making a formulary exception and providing coverage for your drug. Your doctor will most likely need to submit a supporting statement, detailing that your drug is medically necessary and that any alternatives would have an adverse effect.

Note: Some plans will require that you agree to “step therapy” before your exception gets approved. Step therapy is where you try a less expensive drug that’s on the plan’s formulary, prove that it’s not effective or has adverse effects, and then move up a “step” to the more expensive drug you’re requesting.

If the drug you need is on your plan’s formulary, but it’s high-tier or non-preferred, you can still ask your insurer for an exception. If you’re approved, this “tier exception” will help lower your out-of-pocket costs.

Filing an Appeal

If your insurer denies your request for an exception, file an appeal. The exact process will depend on your insurer, but often requires that you work with your doctor to submit an application or letter of appeal.

Filing for an Independent Review

If your insurer denies your appeal, try filing for an independent review through your state’s insurance regulator as a last resort. The process can seem daunting, but the odds are in your favor as many appeals actually get approved.

Here are the details: The independent review can take up to 60 days. If your state doesn’t have an external review process, the federal Department of Health and Human Services (HHS) or a private review organization will oversee the case. Your review won’t cost anything if HHS handles it, but it may cost $25 through your state or a private review organization.

Apply for a Patient Assistance or Manufacturer Co-Pay Program

These programs help people save on specific medications, particularly expensive, brand-name ones that are often not covered by insurance. They can reduce out-of-pocket costs to as little as $0 per month. Keep in mind: patient assistance programs generally serve the uninsured, while manufacturer co-pay programs are for those with insurance.

Where can you find these programs?

In addition to coupons, GoodRx provides savings tips — like information about whether your drug has a related patient assistance and/or manufacturer co-pay program. Just search for your drug on GoodRx.com, and click the “Savings Tips” tab on the left.

Re-Evaluate Your Coverage During Enrollment Period

If you notice that your plan is no longer covering your drug, research whether it’s on another insurer’s formulary. For those of you enrolling in Medicare, be sure to use their Plan Finder to find the plan that best suits your needs.  

General rule of thumb: shop around on the health insurance marketplace during enrollment period. You’ll be surprised by how many plans change year to year.

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