Key takeaways:
Insurance prescription plans don’t cover some medications. This often leaves consumers responsible for the full costs.
If your prescription isn’t covered, you can try generics, biosimilars, or other alternatives that you can afford out of pocket. You may also qualify for patient assistance and manufacturer copay programs that can help you cover costs.
If an insurance plan won’t cover your medication, you can ask for an exception. If that doesn’t work, you can appeal the coverage denial.
It’s frustrating when your health insurance doesn’t cover your medication. A drug that appears on a formulary — the list of medications covered by a health insurance plan — can get dropped anytime. This can happen if a medication is seldom used, there is a generic or biosimilar available, or a more affordable option exists. Whatever the reason, you’re stuck with the full cost even though you have coverage for prescribed medications.
Here’s what you can do if your prescription medication isn’t covered.
What to do when your medication isn’t covered
If your insurance plan won’t pay for a new prescription or if your plan stops covering a medication you already take, you can explore the following options.
1. Talk to a healthcare professional about alternatives
A healthcare professional has no obligation to weigh the costs of your medications. They almost certainly won’t know what’s covered by your prescription plan’s formulary. That’s why it’s up to you to raise concerns about your out-of-pocket costs.
If one of your prescriptions has been dropped from coverage or will cost you more, ask your doctor about generics and alternative medications. These include biosimilars for biologics, which may be more affordable. You may also find a lower price for the prescription with GoodRx.
If you can’t find a more affordable option that works for your condition, a healthcare professional may still be able to help you. You may consider:
Requesting a 90-day prescription and comparing costs with a monthly fill
Asking your prescriber if you can cut a higher-dose pill in half to save money
Asking for free samples of the medication
2. Ask for an exception from your prescription plan
If a healthcare professional can’t help you find an affordable option, ask your insurer about making a formulary exception that provides coverage for your medication. A physician will most likely need to submit a supporting statement (sometimes called a letter of medical necessity) explaining why the medication is needed and that alternatives would not be as effective or would have a side effect.
It’s important to note that some plans will require step therapy before approving your exception. Step therapy is a type of prior authorization that requires you to:
Try a less costly medication that’s on the plan’s formulary
Show that it’s not effective for you or has side effects
Then “step” up to the medication you’re requesting
Even if the medication you need is on your plan’s formulary, it may be in a higher tier. The plan may also consider it nonpreferred. Nonpreferred and higher-tier medications typically cost more out of pocket. In this case, you can ask your plan for a tier exception. If approved, this will help lower your out-of-pocket costs for the medication.
3. Apply for a patient assistance program or manufacturer copay program
Patient assistance programs and manufacturer copay programs help people save on specific medications — particularly costly, brand-name prescriptions that may not be covered by your plan. These programs can reduce out-of-pocket costs to $0 per month for people with and without insurance. Keep in mind: Patient assistance programs generally serve those who are uninsured or underinsured and find their out-of-pocket costs unaffordable. Manufacturer copay programs are typically for people with commercial insurance.
You can usually find these programs on the websites of medication manufacturers. The companies often have partnerships with related company foundations or other nonprofit organizations that connect people in need with deeply discounted or free medication.
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Here are some examples of programs that can help you afford your medications:
AstraZeneca: The AZ & Me AstraZeneca Prescription Savings Program can help you get free medication. You are eligible if you don’t have health insurance or if you have Medicare but still can’t afford your prescriptions. Anyone who has had a life-changing event in the last year may also be eligible. This program has income requirements. AstraZeneca makes many medications but only some are included in the program. Examples include Farxiga, which is used for Type 2 diabetes and other conditions, and Tagrisso, which treats lung cancer.
Johnson & Johnson: This program, formerly known as Janssen CarePath, is called J&J withMe. You can qualify for different savings options on several dozen medications. For instance, the program includes Remicade, Simponi, and Stelara, all of which treat autoimmune conditions. There are no income requirements. The Johnson & Johnson Patient Assistance Program is for people who are uninsured or underinsured. There are income requirements. Those who are eligible receive medication at no cost for up to 1 year.
Lilly Cares: The Lilly Cares Foundation Patient Assistance Program helps people in financial need access more than 20 medications at no cost. Eligible medications include several insulins in different formulations — Humalog, Humulin R, and Trulicity for Type 2 diabetes — and Cialis, which treats benign prostatic hyperplasia and erectile dysfunction.
Merck: MerckHelps assists people with medications through several programs. These include the Merck Patient Assistance Program and Merck Vaccine Patient Assistance Program. MerckHelps also has a program to replace certain medications you received in the hospital. You may be able to get medications at no cost. These include Keytruda, which treats many types of cancer, and Januvia, for Type 2 diabetes.
You can also find these programs and others through GoodRx by searching for your medication and then scrolling down for information about ways to save.
4. Reconsider your health plan during an enrollment period
If your insurance doesn’t cover your prescription medication, consider switching to a plan that has the medication on its formulary. You can do this during your enrollment period. If you are joining original Medicare or a Medicare Advantage plan, be sure to use the Medicare Plan Finder tool to identify a Medicare Part D prescription drug plan that covers the medications you need.
How to file an appeal for prescription drug coverage
If you have explored other options for lowering your prescription costs without success, you can try filing an internal appeal with your insurance plan once your claim for coverage is denied or you can request a coverage determination for a drug you haven’t started taking.
The exact process will depend on your plan, but you are typically required to:
Complete all forms related to an internal appeal as determined by the insurance plan
Submit information you want considered, such as a letter from your doctor explaining that the medication is medically necessary
If you need help, check whether your state or territory has an active consumer assistance program. If you’re enrolled in Medicare, you can also get free help from a State Health Insurance Assistance Program (SHIP) near you.
If your appeal is for a medication you haven’t started taking, the insurance plan must complete the internal review within 30 days. If it’s for a medication you have started taking, the review must be completed within 60 days. In urgent situations, you can request an expedited appeal. In expedited cases, a final decision must be made as soon as required by your medical condition or within 4 business days of receiving your request.
What if your insurance plan denies your appeal for drug coverage?
If your insurance plan rejects your appeal, try requesting 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 because many appeals get approved.
The independent review can take up to 60 days. If your state doesn’t have an external review process, the U.S. Department of Health and Human Services (HHS) or a private review organization will oversee the case. You won’t be charged anything if HHS handles the review, but it may cost up to $25 through your state or a private review organization. If you urgently need the medication, you can request an external review before the internal appeal is complete.
Where can I find more information on medication appeals?
If you’d like more information on the appeals process, check out these sites:
HealthCare.gov has more information on navigating the appeals process.
The Patient Advocate Foundation has tips on how to write and submit an appeal.
The Centers for Medicare & Medicaid Services has information about drug appeals and grievances if you’re covered by Medicare.
The National Association of Insurance Commissioners has information on how to contact the insurance regulator for your state or territory.
Frequently asked questions
A nonformulary drug doesn’t appear on your insurance plan’s list of covered medications. This typically happens when there is a generic version available or if your prescription plan prefers a similar medication deemed safer and more effective. A nonformulary drug is not covered, but you can ask for an exception so that your medication is covered.
Every health insurance plan with prescription coverage has a formulary, or a list of covered medications. Your plan’s summary of benefits and coverage should explain your expected cost sharing in each tier.
When your prescription plan changes, your medications may cost you more or less. That’s because what you’re taking may not be covered or may appear in a different tier of coverage. If your prescription coverage is ending, you may need to prepare to pay for your medications in full or plan to seek assistance from programs that can help you afford your medications.
A nonformulary drug doesn’t appear on your insurance plan’s list of covered medications. This typically happens when there is a generic version available or if your prescription plan prefers a similar medication deemed safer and more effective. A nonformulary drug is not covered, but you can ask for an exception so that your medication is covered.
Every health insurance plan with prescription coverage has a formulary, or a list of covered medications. Your plan’s summary of benefits and coverage should explain your expected cost sharing in each tier.
When your prescription plan changes, your medications may cost you more or less. That’s because what you’re taking may not be covered or may appear in a different tier of coverage. If your prescription coverage is ending, you may need to prepare to pay for your medications in full or plan to seek assistance from programs that can help you afford your medications.
The bottom line
Don’t panic if your prescription plan won’t pay for your medication. This can happen if your treatment isn’t on your plan’s formulary or coverage has been denied. But there are steps you can take to reduce out-of-pocket costs for your medication or get a coverage denial reversed.
First, see if there’s a generic or lower-cost medication that will work for you. You may also qualify for a patient assistance or copay assistance program that can reduce your out-of-pocket costs. If neither of these options works, you can ask your insurance plan for an exception to the formulary so that your medication may be covered. You can formally appeal a coverage denial with an internal review. As a last resort, seek an external appeal. Remember that every objection to your insurance company will require a letter of medical necessity from your prescriber.
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References
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CMS.gov. (2024). HHS-administered federal external review process for health insurance coverage. Centers for Medicare & Medicaid Services.
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