When Your Medication Isn’t Covered by Insurance
Have you ever been stuck at the pharmacy counter, ready to pick up your medication, only to find out your medication isn’t covered by insurance? Have you had the embarrassment of your insurance denying your medication?
Every day, patients across America are told their medication isn’t covered by insurance.
However, a lack of coverage for your medication doesn’t mean there aren’t options. Thankfully, plenty of solutions are available to those who have recently found out that their insurance does not cover their much-needed medication.
This article will walk through the practical steps patients can take after learning that their medication is not covered by insurance.
What It Means When a Medication Isn’t Covered
Wondering why your medication is not covered by insurance?
There may be a few reasons why your insurance plan is not covering your medication. A few of those reasons include:
Non-formulary drugs: Formularies are lists of medications curated for insurance plans. If a drug is not on the formulary, it is most likely not covered by the insurance plan. However, some drugs may not be on the preferred list but could still gain an exception if requested by a provider and approved by the insurance company.
Excluded medications: Not only are these drugs not offered on the formulary, but they are also almost never covered under an exception or prior authorization.
Prior Authorization denial: A prior authorization denial often occurs due to administrative errors, insufficient documentation, a request for an excluded medication, or the insurer’s disagreement with the treatment. Sometimes that may be due to a disagreement about the treatment’s necessity, its ability to meet certain criteria, or because cheaper alternatives have not been tried first.
Why Your Medication isn’t Covered by Insurance
Hearing that your drug is not covered by insurance can be a stressful moment. Whether due to insurance formularies or excluded medications, there are typically a few reasons a denial occurs.
Cost and pricing concerns
Some drugs are extremely expensive. According to the National Association of Insurance Commissioners (NAIC), the insurance industry paid out an average of $ 84.6 billion per month in the first six months of 2024.
For some medications, high costs can outweigh perceived benefits.
Availability of alternatives
For cost and efficiency reasons, an insurance company may determine that an alternative medication could be just as effective as the originally requested medication.
Step therapy requirements
These requirements are also called “fail first” requirements, and they mandate that a patient and their provider try a lower-cost, preferred medication first before agreeing to cover a more expensive, similar-acting drug for a condition.
Requirements often need proof that the initial drug failed, or that the patient cannot take the medication within specific steps and timelines.
Off-label use
Using a medication off-label is often considered “experimental” or “investigational” by the insurance provider. Due to this, most times an insurance company will deny coverage requests for drugs that are being prescribed for off-label use.
Annual formulary changes
Each year, formularies are shaped by agreements among insurance companies, PBMs, and manufacturers. During these annual formulary changes, a medication may be added or dropped, resulting in a denial for a patient who previously had coverage for it.
Employer or plan-specific exclusions
When insurance providers and employers determine employee benefits for a company, some medications or procedures may be specifically excluded.
First Steps to Take When Coverage Is Denied
What do you do when your drug is not covered by insurance?
Learning a drug is not covered can be stressful and frightening, but take a moment to adjust. Other options can help you access affordable medication, though patience and focus may be needed to find them.
When you’re hit with the news that your coverage is denied, follow these steps:
Confirm the Denial
- Carefully review your insurance explanation of benefits (EOB) to understand how your claim was processed and why the medication was denied.
- Ask whether your denial is temporary or permanent. It may become available soon, or they may tell you that the drug is not offered on the insurance formulary and therefore is not covered.
- Check if prior authorization is required. If denied, take the next step to get approval by following the outlined appeals or submission process.
Talk to Your Pharmacist
Ask your pharmacist to check your plan’s formulary. They can confirm if a drug is not covered or if restrictions like prior authorization are involved.
First, ask your pharmacist if there are lower-cost yet equally effective therapeutic alternatives. Then, discuss how these options compare to your current treatment.
Ask about the price difference between paying cash and using insurance so you can compare total costs and decide the best option.
Inquire about available discount programs. Your pharmacist may know of savings or assistance programs for your medication.
Contact Your Healthcare Provider
Contact your healthcare provider to discuss alternatives, gather necessary documentation, and ask if dosage or drug changes could improve coverage chances.
How to Appeal an Insurance Denial
Understand these key details about appealing an insurance denial.
What is an insurance denial appeal?
This is a formal request sent to your insurance company to reconsider their decision regarding your medication coverage. Legally, insurance providers must offer specific steps that allow policyholders to dispute why they believe their treatment should be covered.
Patients, authorized representatives, and healthcare providers can submit an appeal to the insurance provider and answer any questions during the appeal process.
In order to properly file a medication coverage appeal, a patient or their authorized representative must submit:
- An appeal letter formally outlining why the denial is incorrect. This should include patient and policy information, claim number, and specific reasons for the appeal.
- The denial letter from the insurance provider
- A letter of medical necessity from your healthcare provider explaining why your treatment is medically necessary
- Medical records that indicate the need for the medication
- An insurance policy/evidence of coverage that shows the medication should be covered
- Correspondence and logs of all communications
- Scientific/medical studies that support that the treatment is the necessary standard of care.
Denial appeals can and do succeed. Typically, an acceptance after an appeal is granted when the denial is due to incomplete, missing, or incorrectly coded documentation.
Getting a decision on a medication denial appeal can take up to 30 days for standard internal appeals or as little as 72 hours for expedited appeals.
Patient Assistance Programs and Financial Help
Thankfully, other solutions do exist.
Manufacturer Patient Assistance Programs (PAPs)
Manufacturers offer Patient Assistance Programs (PAPs) to provide eligible patients with medications at reduced or no cost and help alleviate their financial burden.
Eligibility requirements for these programs often revolve around four main areas:
- Income status
- Residency
- Insurance coverage status
- Prescription
While patients can apply for these programs on their own, the programs are often complex and overwhelming. Paperwork, red tape, insider knowledge, and expertise on the process can all become major obstacles to approval.
Copay and Cost-Sharing Assistance
Both copay cards and cost-sharing assistance often offer help for brand-name drugs that are too expensive to pay out-of-pocket costs.
However, they can be unpredictable, with inconsistent availability and limited financial assistance for patients.
Nonprofit and State Assistance Programs
Other programs, including disease-specific foundations and state medication assistance programs, offer financial assistance towards the cost of medications and treatments. These programs are typically most helpful for those seeking support with specialized medications or for patients who need government support with their costs.
Manufacturer and Pharmacy Support Options
When your medication isn’t covered by insurance, manufacturer and pharmacy support options may help. However, many drug companies offer medication assistance programs (PAPs).
Meanwhile, copay cards are generally intended for patients with commercial insurance and help lower their out-of-pocket costs. Full assistance programs, on the other hand, may provide the medication itself for free or at a steep discount, but are usually limited to uninsured or underinsured patients.
Unfortunately, government-insured patients, such as those on Medicare or Medicaid, are often excluded from copay card programs.
Pharmacies can also offer pharmacy advocacy and discount options. Pharmacists may help to identify manufacturer programs, apply available savings cards, or suggest cash-pay discounts and third-party pricing tools. Some pharmacies even help to find the lowest available price.
However, these options have limitations. Eligibility rules, limited funding, medication exclusions, and temporary approvals mean that assistance may not be reliable or long-term.
Preventing Coverage Issues in the Future
To help prevent being caught by surprise at the counter, patients may wish to follow these steps to ensure they are well aware of their medication coverage status.
- Reviewing formularies during open enrollment
- Asking coverage questions before starting new medications
- Keeping records of past approvals and denials
- Working proactively with your healthcare team
How Prescription Assistance Programs Help When Coverage Is Denied
Prescription Assistance programs offer help to those seeking access to affordable medications who qualify.
Offered by manufacturers, the programs provide high-cost brand-name medications at low or no cost to patients.
However, the programs require extensive application paperwork and documentation, as well as ongoing renewals for consistent delivery.
Patients often turn to services like Prescription Hope to help navigate accessing their medications.
Prescription Hope is an advocacy program that assists patients seeking to apply for Prescription Assistance Programs. When insurance and discounts fail, organizations like Prescription Hope can help patients access their life-saving medication at an affordable rate.
Conclusion: You Still Have Options if Your Medication isn’t Covered by Insurance
If you need solutions because your medication isn’t covered by insurance, options do exist. Thankfully, these solutions are only a phone call or a simple enrollment form away.
Every day, patients across America are denied treatment or medication by their insurance companies. It’s important that if this happens to you, you do not panic, but take action. Seek help, ask questions, and remember that solutions do exist.
