Health insurance helps cover the cost of most prescription medications.
Each plan has a formulary, a list of approved medicines that cost less through the insurer. You may be able to buy other medications, but those listed on your plan's formulary will cost less.
Which prescriptions does my health insurance plan cover?
You can find a list of covered prescriptions on your insurer's website. It will show you which drug, generic, and dosage it covers.
Check your insurer's Summary of Benefits and Coverage. You can receive this document directly from your insurer.
Alternatively, you can call the insurer and ask what is covered. Find their phone number on their website.
What if my plan no longer covers my prescription?
If you are at the pharmacy and your plan no longer covers your prescription, call the insurance company. Some insurers can offer a one-time prescription refill after you first enroll. It provides you time to discuss alternatives with your doctor.
Suppose you cannot receive a one-time refill. The insurer allows you to appeal for an exception and potentially cover your drug. Your doctor must confirm your health condition and affirm the medication is appropriate for your treatment plan. Also, the doctor confirms that:
- All other covered drugs were not or will not be as effective as the medication prescribed
- Alternative drugs cause or will cause harmful side effects
- If the dosage prescribed is higher than the formulary covers, the dosage did not work for your condition or will not work based on your physical or mental circumstances.
Some insurers may provide access to the drug while you wait for the exception decision.
If the insurance company grants your exception, they will typically treat it like the most expensive covered drugs. Typically, your copay counts toward your deductible and/or out-of-pocket limit.
What is the insurer denies the exception request?
You have the right to appeal the decision your health insurer makes. An independent third party will review the circumstances and decisions.
Can I use my regular pharmacy with my new health insurance plan?
Just as your insurer uses in-network providers, they also have preferred pharmacies.
Check with your insurer to find out if your preferred pharmacy is in their coverage network.
Alternatively, most insurers permit and recommend that people use the insurance company's preferred mail-order pharmacy. It saves you money and time.
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