1st Quarter 2019

Your Insurer Won’t Cover Your Prescription Drugs — Now What?

What can you do if your doctor prescribes a drug that isn’t covered by your insurance? Two of the largest pharmacy benefit managers, which provide drug coverage for many health plans, dropped dozens of drugs from their formularies (their lists of covered drugs) in 2019. If you discover that your drug is no longer covered, you may have several options:

Find out if you just need to submit some extra paperwork. More health plans are requiring prior authorization, which requires your doctor to fill out a form explaining why you need to use that drug before it will be covered.

Ask your doctor if there are any less-expensive substitutes. You may be able to take a generic version of the drug, or there may be a “therapeutic alternative” that can also treat the condition and may be covered by your insurance plan with a small co-pay.

Find out if you can pay cash and use a coupon or discount card. Your doctor or pharmacist may know about drug discounts, rebates, or coupon programs. You can go to GoodRx.com to find coupons and a discount card, and compare prices at several pharmacies in your area.

Consider appealing a denial. If you can’t switch to a covered drug, ask your health plan provider about the steps required to appeal a denial. Your doctor usually needs to submit paperwork explaining why a drug is medically necessary  such as if you’re in the middle of treatment. If you need the drug quickly, you may be able to file an expedited appeal.

Find out if the drug manufacturer has a patient assistance program. These arrangements help pay for the drug if you lack coverage or have high co-payments for the medication. Several charitable foundations also provide assistance programs. Although income limits may apply to some of these programs, the thresholds can be quite high. Search for programs by drug at www.needymeds.org.

This article contains information obtained from outside sources and it references external websites. While we believe the information and external websites to be reliable, we cannot guarantee their complete accuracy.

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