Some of the most frustrating words you can hear at the pharmacy are, “I’m sorry but your medication is not covered by your insurance.” The reaction I receive most frequently from customers is a look of frustration and a feeling of being helpless. The great news for you is that there are actions that can be taken so you can still get your medication.
So, What can you do when your prescription medication isn’t covered by your insurance? Your options include:
- Pay out of pocket with a prescription discount card
- Get samples from your doctor
- Ask the prescriber to file for a prior authorization
- Talk with the pharmacist to see if there are covered options
- Search online to see if there is a free trial coupon or copay savings card from the drug manufacturer
- Apply for a patient assistance program
- Switch insurances during open enrollment
I’ll discuss each of these options in more detail as well as reasons why your medication may not be covered by your prescription insurance.
4 Reasons Why Your Medication May Not be Covered by Your Insurance.
Prescription insurance is a very muddy and complicated topic to discuss but there are a few clear reasons a medication may not be covered.
1. The medication is not on the formulary
What’s a formulary?
Each insurance company has a group of brand/generic medications that it has contracted pricing on for its members. This list of covered drugs is called a formulary. The purpose of the list is to help control costs incurred by the prescription coverage portion of a healthcare plan. Any med not listed on the formulary will trigger a rejection at the pharmacy.
You can request a copy of your prescription plan’s formulary from the insurance company itself. Thankfully, many companies publish their formularies online either in a downloadable format or an easily searchable database. If you have trouble just call the customer service number on the back of your insurance card and the associate will be able to answer any questions you may have.
The formulary lists which medications are covered but insurance plans also divide their list of medications into “Tiers”. These tiers are groups of medications usually broken down by cost from cheapest, Tier 1 generic medications, to most expensive, Tier 4 non-preferred brand medications. The lower the tier the cheaper your copay.
2. Step Therapy Required
Insurance companies attempt to reduce overall costs for their plan sponsors, think your employer or Medicare. Some medications have cheaper alternatives that may work equally as well.
An insurance company may require you to try the cheapest medication to treat your condition before they will approve the more expensive medication your doctor prescribed for you. This scenario is called “Step Therapy”.
After your try the cheaper medication for the required length of time and you and your doctor have determined you still require to be treated with the more expensive medication the insurance usually allows the claim to process at the pharmacy without any troubles.
There are times where the doctor has to submit information from your medical chart to the insurance for them to review and approve the more expensive treatment. This process is called a “prior authorization” and is the most frustrating process for patients, prescribers, and pharmacies combined.
3. Prior Authorization Required
My doctor wrote for it, why can’t I just get it?
Your insurance company could require a prior authorization for a variety of different reasons. A few examples of those reasons include:1
- Writing for a brand name medication when a generic is available
- The condition being treated is cosmetic or deemed “non-life threatening”
- Medication dosage is higher than normally seen
- The medication may have dangerous interactions with your current therapy
- The quantity of the drug requested
Some of the above reasons have solutions your insurance company will want you to try before approving your prior authorization. These alternatives are all part of what’s called ‘fail first’ policies. These policies are simply protocols that must be tried before what your doctor has actually prescribed will be covered.
In the case of reason #1, if there is a cheaper brand or generic available your prescription plan will have you try that medication first unless the doctor can explain that the brand name medication is medically necessary.
In the case of reason #3, your insurance may have you try a “step-up” approach as described above. This simply means that if your dose can be made with a different strength of a less expensive product, they will cover that medication instead.
Brand/generic example:4
- Your doctor writes for Nexium® 40mg capsules, but your insurance doesn’t cover the brand name product. They do however cover the generic esomeprazole 40mg capsule.
“Step Up/Fail First” example:6
- Your doctor writes for Lotrel® (amlodipine-benazepril combination blood pressure agent) but the insurance denies the combo product. They will, however, cover filling a prescription for amlodipine and a prescription for benazepril.
- Your doctor writes for Humalog®, but the insurance denies coverage. They will cover the medication AFTER you’ve tried Novolog®.
A lot of work goes into getting a prior authorization approved; there’s paperwork, phone calls, and waiting involved. It takes a coordinated effort from you, your pharmacy, and your physician. If you file an urgent request, you may get a response as soon as 24 hours. However, some prior authorization requests can be under review for up to 15 days.3
Unfortunately, even if your insurance company decides to approve your prior authorization and cover your medication, the approval isn’t always permanent. Some approvals only last for a set amount of time and you have to reapply when that timeframe has expired.
While it would be nice to think that eventually your PA will be approved, this isn’t this case. However, if your insurance company decides to deny your prior authorization request you can go through an appeals process. It will require more documentation from your physician, but if you feel your denial was unfair it might be a fight you can win.
4. The drug is available OTC
Many insurance companies, with the exception of medicaid, will not pay for medications that are available over the counter, even if a prescription version exists. Some take it a step farther and won’t cover an entire class of medications if an over-the-counter option exists.
Examples of medications in this category that I see commonly rejected are:
- Heartburn medications such as omeprazole (Prilosec), lansoprazole (Prevacid), esomeprazole (Nexium), and ranitidine (Zantac)
- Stool softener and laxatives like Miralax, Colace, Dulcolax, magnesium citrate, and fiber supplements
- Probiotics
- Vitamins and supplements
- Allergy treatments like Flonase, Nasacort, Rhinocort, Claritin, Zyrtec, Allegra, and Benadryl
In this instance your only option is to buy the product over the counter. Amazon is a great place to get these medications super cheap and have them delivered to your door.
What can you do when your drug is not covered by your insurance?
Use a prescription discount card to pay out of pocket
The simplest, most efficient method of getting your medication is to just pay for it out-of-pocket yourself. If you don’t know which discount card to use check out the list of prescription discount cards I recommend.
Prescription discount cards can provide savings of up to 80% off medication costs, are super easy to sign up for, and might even provide better pricing than your insurance co-pays.
Unlike standard prescription insurance coverage, discount cards don’t require you to meet a deductible, you don’t have monthly paycheck deductions, and you aren’t limited by certain time frames to refill your medications. These cards are free, provide discounts on certain brand and generic outpatient medications, and usually don’t expire.
If the medication is too expensive for you even with the discount card price then you, your pharmacist, and prescriber will have to jump through some extra hoops.
Get Medication Samples From Your Doctor
If you are prescribed a brand name medication more than likely the manufacturers drug rep has visited your prescriber’s office. The drug reps commonly provide education and prescribing information about the drugs their company makes to entice doctors to prescribe their medications.
To help get patients to start taking the companies medications drug reps leave manufacturer copay cards, free trial cards, or even small sample bottles of the medication in the doctor’s office.
If you find that your medication is rejected by your insurance ask your prescriber if they have any samples they can give you. They won’t be able to give you samples for a long time so they will also have to start the prior authorization process described below.
Starting with samples may get you through the waiting period of a prior authorization approval and possibly establish your need for the brand name product.
File for a Prior Authorization
Prior authorizations are the bane of patients, pharmacies, and doctors offices alike. They impede patient care in most cases and are an administrative burden on doctors and pharmacies.
What exactly is a prior authorization?
I alluded to a prior authorization above but now I’ll explain exactly what is involved.
When a pharmacy adjudicates a claim for a prescription and the insurance rejects the claim and indicates that a prior authorization is required or the drug is not covered the process starts.
The pharmacy, as a convenience to the patient, starts the prior authorization process by either faxing the required insurance contact information to the doctors office or submitting the request via an electronic automated system called CoverMyMeds.
The responsibility of filing for a prior authorization lies with the prescriber’s office. The insurance requires the office to submit a completed prior authorization form that documents the necessity for the prescribed medication and supporting documents from your medical chart.
Once the doctor submits the required information to the insurance company the review process begins. If the information the doctor has submitted satisfies the insurance requirements then the prior authorization is approved.
Typically, you and the prescriber will receive a letter in the mail or via fax. Rarely, the pharmacy is notified so if you get an approval letter please call the pharmacy to process your claim.
If the insurance requirements are not met then the prescriber’s office is notified and asked to either submit the missing information or the prior authorization is denied.
The prior authorization fell through, what options do I have to get my medication covered?
Ask your pharmacist if a covered alternative exists
In some instances, there may be a different strength of the drug that your insurance will cover that can be used to make your dose (i.e., using two tabs of a lower strength or halving a tablet of a higher strength). If you need help coming up with options to discuss with your doctor, talk with your local pharmacist.
Many people have the misconception that the pharmacy knows every drug covered on every drug plan. Pharmacists can typically make recommendations based on their experience but drug coverage varies greatly between insurance carriers and changes throughout the year, on a whim it seems like at times.
To help your pharmacist determine is an appropriate alternative exists please take your formulary information to the pharmacy with you or have it available when you call.
Prescription Assistance Programs
For medications not covered by your insurance that are too costly for you to pay cash for, there might a prescription assistance program available. Personally, as a college student living on grants and scholarships, prescription assistance was the only way I was able to get the meds I needed while in school.
Non-profit organizations, drug companies, and even your local government have programs like this in place, you just have to do the research to find out what their requirements are (www.needymeds.org and www.pparx.org are both great resources).
The Nuclear Option
The most drastic move you can make if you find yourself in the position of having your medication denied is to switch insurance companies entirely. The problem with this option is that you are typically only allowed to switch carriers once a year during open enrollment.
Sorting through all the insurance options during your employer’s enrollment period can feel like navigating through the Amazon jungle without a compass. Trying to decipher level I vs. level II coverage and out of pocket deductibles can feel like a foreign language. It’s easy to just look at how much will be deducted from your check monthly and go with the cheapest option. I mean you don’t really get sick that often anyway, right?
I’m sure I’m not the only person who has thought this way. However, if you find yourself in a situation where certain meds you need are denied, it may be helpful to review if changing your insurance coverage could help your situation. Talking with your human resources representative or even the insurance company itself could help you pick a plan that better fits your long-term healthcare needs.
Switching medicare plans
Most medicare enrollees will have to wait until October during open enrollment to change drug plans. Unfortunately, those elections don’t take effect until January 1st of the following year.
The good news is that there are special circumstances that allow individuals to switch during the plan year. Those are during the medicare advantage special open enrollment period and anytime during the year if you decide to switch to a 5-Star rated medicare prescription drug plan.
To learn more about how to switch medicare prescription drug plans check out Medicare.gov or the information from The National Council for Aging.
Doing the prescription two-step
Navigating your way through the healthcare system can seem like a dance at times. But I wouldn’t suggest you ask your local DJ to play the prescription two-step at your next party, lol. There are ways to get the meds you need without dishing out cash, it just takes a little finesse.
My hope is that in understanding more about the prior authorization process you’re better prepared if you find yourself in this situation. Most insurance companies have an online list of the medications included in their formulary, check it out. And if you need help getting a medication, now you know some non-insurance ways to get that medication.
Prior authorizations can be a pain in the butt and aren’t always fair, but let’s think of the alternative…if every high dollar medication that was prescribed was covered by your healthcare insurance who would eventually take on that cost?? Yep, YOU, the consumer. That would mean higher deductibles, more money paid out each month for health insurance, etc. It would be the equivalent of those pesky car insurance price raises caused not by you, but by the “drivers in your area”.