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What should you do if your medication isn鈥檛 covered by insurance? 4 tips and tactics, plus how to file an appeal

It鈥檚 frustrating when your health insurance doesn鈥檛 cover your medication. A drug that appears on a 鈥� the list of medications covered by a 鈥� anytime. This can happen if a medication is seldom used, there is a generic or available, or a more affordable option exists. Whatever the reason, you鈥檙e stuck with the full cost even though you have coverage for prescribed medications.

, a platform for medication savings, shares what you can do if your prescription medication isn鈥檛 covered.

Key takeaways:

• Insurance prescription plans don鈥檛 cover some medications. This often leaves consumers responsible for the full costs.
• If your prescription isn鈥檛 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鈥檛 cover your medication, you can ask for an exception. If that doesn鈥檛 work, you can appeal the coverage denial.

What to do when your medication isn鈥檛 covered

If your insurance plan won鈥檛 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鈥檛 know what鈥檚 covered by your prescription plan鈥檚 formulary. That鈥檚 why it鈥檚 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 , which may be more affordable.

If you can鈥檛 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鈥檛 help you find an affordable option, 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 ) explaining why the medication is needed and that alternatives would not be as effective or would have a side effect.

It鈥檚 important to note that some plans will require before approving your exception. Step therapy is a type of that requires you to:

• Try a less costly medication that鈥檚 on the plan鈥檚 formulary.
• Show that it鈥檚 not effective for you or has side effects.
• Then 鈥渟tep鈥� up to the medication you鈥檙e requesting.

Even if the medication you need is on your plan鈥檚 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 for the medication.

3. Apply for a patient assistance program or manufacturer copay program

and help people save on specific medications 鈥� 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.

Here are some examples of programs that can help you afford your medications:

• AstraZeneca: The can help you get free medication. You are eligible if you don鈥檛 have health insurance or if you have but still can鈥檛 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 . Examples include , which is used for and other conditions, and , which treats .
• Johnson & Johnson: This program, formerly known as Janssen CarePath, is called . You can qualify for different savings options on several dozen medications. For instance, the program includes , , and , all of which treat . There are no income requirements. The is for people who are uninsured or underinsured. There are income requirements. Those who are eligible receive medication at no cost for up to one year.
• Lilly Cares: The helps people in financial need access at no cost. Eligible medications include several insulins in different formulations 鈥� , , and for Type 2 diabetes 鈥� and Cialis, which treats and .
• Merck: assists people with medications through . These include the and . MerckHelps also has a program to replace certain medications you received in the hospital. You may be able to get at no cost. These include , which treats many types of , and , for Type 2 diabetes.

4. Reconsider your health plan during an enrollment period

If your insurance doesn鈥檛 cover your prescription medication, consider switching to a plan that has the drug 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 tool to identify a 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 with your insurance plan once your claim for coverage is denied or you can request a coverage determination for a drug you haven鈥檛 started taking.

The 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 . If you鈥檙e enrolled in Medicare, you can also get from a (SHIP) near you.

If your appeal is for a medication you haven鈥檛 started taking, the insurance plan must complete the internal review within 30 days. If it鈥檚 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 four 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 as a last resort. The process can seem daunting, but the odds are in your favor because many appeals get approved.

The can take up to 60 days. If your state doesn鈥檛 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鈥檛 be charged anything if , but it may 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鈥檇 like more information on the appeals process, check out these sites:

• has more information on navigating the appeals process.
• The has tips on how to write and submit an appeal.
• The has information about drug appeals and grievances .
• The has information on how to contact the insurance regulator for your state or territory.

Frequently asked questions

What is a nonformulary drug?

A doesn鈥檛 appear on your insurance plan鈥檚 . 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.

How do you find out if your insurance covers your medication?

Every health insurance plan with prescription coverage has a formulary, or a list of covered medications. Your plan鈥檚 should explain your expected cost sharing in each tier.

What happens to your prescriptions when your insurance changes?

When your prescription plan changes, your medications may cost you more or less. That鈥檚 because what you鈥檙e taking may not be covered, may appear in a different tier of coverage, or may have a different copay or coinsurance amount. If your prescription coverage is ending, you may need to prepare to pay for your medications in full or plan to that can help you .

The bottom line

Don鈥檛 panic if your prescription plan won鈥檛 pay for your medication. This can happen if your treatment isn鈥檛 on your plan鈥檚 formulary or if 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鈥檚 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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