What to do when your medication is not covered by insurance

Key takeaways

• If your insurer won’t cover your prescribed drug, you can ask your healthcare professional about generic versions or alternative medications in the same drug class that may be covered and work similarly for your condition.
• You have the right to request prior authorization or a formulary exception from your insurance company, and if they deny coverage, you can file internal and external appeals to challenge their decision.
• Manufacturer copay programs, prescription discount cards, and patient assistance programs can significantly reduce out-of-pocket costs when insurance won’t cover your medication, with some discount cards offering savings up to 80%.

Overview

Prescription medications are essential to many, but often come at a high cost. When your health insurance plan doesn’t pay for your prescription, or you have a high deductible, you may want to consider other ways to fill the payment gap. 

There are many options out there if your health insurance doesn’t cover your medication.

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Ask about generics or alternative medications

When your insurance plan doesn’t cover a medication, you can ask a healthcare professional if another drug may have the same effects.

Generic medications are among your options. These medications have the same active ingredient as the corresponding brand names. For example, the antidepressant Zoloft also comes in generic form as its active ingredient, sertraline. An active ingredient is what makes a drug work.

Generic medications work the same way as the brand-name medications and have also met the Food and Drug Administration (FDA) safety standards. The difference may be in the dosage, fillers or inactive ingredients, or administration forms.

Generic medications are usually more affordable than brand names, and your insurance is more likely to cover them. However, not all brand-name medications have a corresponding generic product.

If your health insurance doesn’t cover a prescribed drug, a different medication approved for the same use may also be an alternative.

A group of medications to treat the same condition that work similarly is known as a drug class. You may ask the prescribing healthcare professional if other medications in the same drug class are suitable for your individual requirements, or you can ask for a medication from a different drug class that treats the same condition.

For example, medications for diabetes come in different forms and active ingredients. If your insurance doesn’t cover one, they may cover another. The alternative drug may have different acting mechanisms or side effects, but they could meet the same health management goals. 

To check whether your health insurance plan covers a specific medication, you can review your explanation of benefits document. This is typically available on the company’s site, or an agent may be able to send it to you.

If you need help covering the cost of medications, the free Optum Perks Discount Card could help you save up to 80% on prescription drugs. Plus, you can now get them delivered to your home in as little as 3 days. Search for your medication here.

Request an exception or submit a prior authorization

If your insurer does not cover your medication, you have two additional options. One is to ask for special authorization from your insurer, and the other is to request a formulary exception.

In both cases, you request the insurance company to cover the cost of a medication they don’t usually pay for, but that is critical to your health.

You may start a prior authorization request for medications by asking a healthcare professional to complete a form from your insurer. Typically, they’ll have to explain why you need this medication and how soon you need it. Your insurance company will respond within a few days with their decision. You may appeal the decision once.

The healthcare professional may also submit a formulary exception, asking the insurance company to cover the prescribed medication as an exception. They’d have to explain why no other medication is as effective in your particular case.

Appeal a decision

If your insurance company denies a request or won’t cover a medication after you request an exception, you have the option of filing an appeal to their decision. If they deny coverage after an internal appeal, you may request an external review.

An internal appeal happens after a denial of a prior authorization or formulary exception. You can use the insurer’s forms to file an appeal or contact them with your name, claim number, and health insurance policy number. Your appeal should include a doctor’s letter explaining why you need the medication.

How much time you have to file an appeal may depend on the type of insurance you have. In general, you may have up to 6 months to file an internal appeal with a private health insurance company after they deny a request.

They must respond to the appeal within 30 days of receiving it if you have not yet started using the medication, or 60 days if you have covered the cost yourself.

An external review involves a neutral third party that reviews the case and makes a decision. 

External review processes depend on your state regulations and type of insurance, but must meet minimum federal standards for consumer protection.

The written notification of denial of an internal appeal typically includes all the information about options for third-party reviews. You may also find information about appeals on the explanation of benefits, which is a document your health insurance provides after you enroll.

A decision from an external reviewer should come no later than 45 days after your request is received. If it’s filed as an urgent request, you may hear from them sooner.

For specific appeal requirements and times, you may need to contact your insurer directly.

Try a manufacturer copay program

If your insurance plan doesn’t cover your medication, the drug manufacturer may offer cost-reduction options. Some pharmaceutical companies provide manufacturer coupons and patient assistance programs. 

Manufacturer coupons reduce your out-of-pocket costs. The manufacturer negotiates with a pharmacy and proposes to reimburse any discounts on the price you pay when you pick up your prescription.

A patient assistance program allows you to get the medication directly from the maker at a reduced cost. 

To check whether this option is available to you, visit the drug manufacturer’s website or contact them directly to ask about discount programs.

Switch insurance plans

The list of medications that an insurance company covers varies according to the insurance plan. Your plan may not cover the drug you need, but the same company may have one or more plans that do.

If you want to consider changing insurance plans, you may do so during open enrollment, when insurers set time for you to enroll or make changes to your coverage.

Pay out-of-pocket

Even if your insurer does not cover the cost of your medication, your healthcare professional’s prescription is still valid. You still have the option to use your own funds to cover the cost of medications.

Copay and premium assistance programs through states and nonprofit organizations may be available in your area. They may help reduce the cost of insurance and help cover copays.

While these might not help with the medication your insurance won’t cover, they might help reduce other medical expenses.

Save with discount cards or coupons

Prescription discount cards, like the one Optum Perks offers, work with participating pharmacies to reduce the cost of some medications by up to 80%.

Legitimate discount card programs are free of charge to you, don’t request personal information, and provide significant savings when you show them at your pharmacy.

You may use your discount cards for multiple prescriptions. All you have to do is show the printed card or on your phone and ask the pharmacist for the cost of the medication after the discount. If, for some reason, the pharmacy doesn’t accept your card, try again at another location.

Drug coupons also help you save on your prescriptions. You may use your coupon for the indicated medication only.

With Optum Perks drug coupons, all you have to do is search for your specific medication, find the corresponding coupon, download it to your phone, and show it at the pharmacy.

You may not use discount cards or coupons at the same time or together with your insurance card if your medication is covered. You have to use one or the other at the time of paying for the drug. You can ask the pharmacist which of the two gives you a better price.

Common medications not covered by insurance

The list of medications not covered by insurance varies widely depending on your insurer and plan.

Always check with your insurer to confirm coverage for a specific medication.

Some medications that some insurers may not cover include:

• acalabrutinib (Calquence)
• infliximab (Remicade)
• tralokinumab-ldrm (Adbry)
• methoxy polyethylene glycol-epoetin beta (Mircera)
• naltrexone bupropion (Contrave)

Insurers also may not cover medications used for an off-label purpose, such as if Ozempic is being used for weight management.

Even if a medication appears on your coverage documents, it might still require prior authorization before the insurer pays for it.

Summary

If your health insurance plan doesn’t cover your prescription, you may appeal their decision, request an exception, ask the drug manufacturer for a reduction in the cost, or use a discount card or coupon.

You may also want to switch to a different plan under your insurance company or ask a prescribing healthcare professional for alternative medications that may serve the same purpose. 

Download the free Optum Perks Discount Card to save up to 80% on many prescription medications. Plus, you can now get them delivered to your home in as little as 3 days. Search for your medication here.

Related articles

• Prescription cards vs. insurance cards
• How to pick a health insurance plan
• Prescription cards and insurance deductibles

Disclaimer: While Optum Perks strives for factual, comprehensive, and current information, this article is not a substitute for a licensed healthcare professional’s expertise. Always consult a doctor before taking or discontinuing any medication. Drug information is subject to change and may not cover all uses, directions, precautions, warnings, interactions, reactions, or adverse effects. The lack of a warning does not guarantee a drug’s safety, effectiveness, or appropriateness for all patients or specific uses.