So, you've been diagnosed with a condition by your doctor, you go to your local pharmacy and the pharmacist tells you that the drug your doctor prescribed is not covered by your insurance.
Doesn't make sense does it? How could the hundreds of dollars you spend on insurance each month not help cover a drug that you actually need?! Well if you have experienced this frustration you are not alone. Many Americans are finding out more and more everyday that the prescription that they need to help balance or save their life will cost them a fortune because their insurance company won't cover it. So what do you do?
To find out which prescriptions are and are not covered through your plan:
- Visit your insurer's website to review a list of prescriptions your plan covers.
- Call your insurer directly to find out what is and isn't covered. Have your plan information available. The number is available on your insurance card, the insurer's website, or the detailed plan description in your Marketplace account.
- Review any coverage materials that your plan mailed to you. Look specifically for your Summary of Benefits and Coverage or if you bought insurance through your state's Marketplace, then use the link that appears in the detailed description of your plan's Marketplace account .
Your insurance doesn't cover the medicine your doctor prescribed. Now what?
When your insurance company won't cover a medicine, it's usually because it's not on your insurance plan's "formulary," or list of medicines covered by your plan. Here are some tips to help you get the medicine that you need.
- Ask your doctor if there is a medicine that is covered that will work for you
Sometimes a medicine that is on your formulary will work as effectively treat your condition. Talk with your doctor about the pro's and con's of taking a different medication.
- Pay for it yourself
Sometimes there isn't a big difference between the cost of the medicine if you pay for it yourself and your insurance plan's co-pay. In rare cases, it is actually less expensive to pay for the medicine without your plan than with your plan.
- Have your doctor to request an "exception"
Your doctor can appeal to your insurance company to cover this medication as an excpetion based on medical necessity. This exception would be because your doctor feels that another medicine will not work for you as effectively, or maybe you are allergic to the other possible medicines on the formulary.
- Write a formal appeal
If your doctor appeals for an exception and is denied, you can further appeal that decision by submitting a letter of appeal to your insurance. For more information about what to include in your letter and to see sample appeal letters visit patientadovcate.org
- Use a free drug coupon
Your insurance company wont cover it but there are coupons for drugs that aren't covered on NonCoveredDrugs.com. You can find still find big savings on your non-covered drugs without it breaking the bank by printing them out or just showing them on your phone at your local pharmacy.