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.
These are some of the options you may have when prescription cost coverage is a problem.
Ask about generics or alternative medications
When your insurance plan doesn’t cover a medication, you can ask your 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.
Generic medications work in the same way as the brand names 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. Not all brand-name medications have a corresponding generic product.
A different medication approved for the same use may also be an alternative if your health insurance doesn’t cover a prescribed drug. You may ask your healthcare professional if other medications or active ingredients are suitable for your individual requirements.
For example, medications for diabetes come in different forms and active ingredients. If your insurance doesn’t cover one, they may cover another one. The alternative drug may have different acting mechanisms or side effects but could meet the same health management goals.
To check if 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 may be sent to you by an agent.
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. Follow the links on drug names for savings on that medication, or search for a specific drug here.
Request 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 asking your healthcare professional to fill out a form that your insurer provides. Typically, they’ll have to explain why you need this medication and how soon you need it.
After a few days, you’ll hear back from your insurance company regarding their decision. You may appeal the decision once.
Your 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 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 (EOB), 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.
