What can I do if my health insurance denied coverage of my medication?

What can you do when your health plan won’t cover your medication? It’s frustrating to find out that your insurance has denied coverage for a medication you need, but there are various possible solutions to keep in mind if you find yourself in this situation.

How to get medication approved by insurance

Once you know why your health plan has denied coverage for your medication, there are various steps you can take:

1. Consider alternative medications or seek a formulary exception.

If the medication isn’t on your plan’s formulary – meaning the plan generally doesn’t cover this drug under any circumstances – you should talk with your doctor about alternatives.

You should be able to find your plan’s formulary list on the plan’s website, or you can call the plan to ask for help locating the formulary if you’re having trouble finding it.

If there’s an alternative drug that is on your plan’s formulary and that will treat your condition, your doctor can switch your prescription to that drug.

If your doctor says there is no other alternative that will work, you and your doctor can work together to file a formulary exception with your health plan.¹ If the formulary exception is denied, you’ll have the opportunity to file an appeal, which is discussed below.

2. Complete necessary prior authorization paperwork.

If your plan requires prior authorization for a certain prescription drug, you won’t have coverage for that drug until the prior authorization is approved. Assuming you’re using a doctor who is in-network with your health plan, they will be able to submit the paperwork that your health plan requires for the prior authorization review.³

But it’s in your best interest to stay involved in the process and make sure that the health plan has everything necessary for the prior authorization review.

If the prior authorization is denied, you’ll have an opportunity to appeal the decision.

3. If your plan requires step therapy or a specific diagnosis, discuss alternatives with your doctor.

If your plan requires step therapy before it covers your medication, you can discuss your alternatives with your doctor. They can prescribe a lower-cost alternative covered by your plan, and you and your doctor can keep track of how well it works for you.

If it doesn’t work, and the details are documented for your health plan, they may agree to cover the more expensive drug.

But if your doctor believes that the lower-cost alternatives would be unsuitable for you, they can file an exception request with your health plan, which may or may not be approved.⁴

If a medication that will work for you is still not approved by your health plan, you and your doctor can begin the appeals process, discussed below.

If your plan will only cover your drug for certain conditions, you’ll need to discuss the specifics with your doctor. It could be that the doctor just didn’t include the extent of your medical conditions in the prior authorization paperwork.

In that case, more complete information being provided to your plan might solve the problem. If you don’t have a condition for which your plan approves the drug, you can look for alternative drug options or file an appeal with your health plan.

How to appeal when your medication is not covered by insurance

With almost all health plans, you have the right to an internal appeal if coverage is denied,⁶ and if that’s unsuccessful, an external review with an independent third party.⁷ (Note that the ACA guarantees access to internal appeals and external reviews as long as your health plan isn’t grandfathered, and as long as it’s not a plan that isn’t subject to ACA rules, such as short-term health insurance or fixed-indemnity coverage.)

Assuming you and your doctor have provided all of the information that your health plan has requested and the plan is still denying coverage for the medication you need, starting the appeals process is your next step.

Although guaranteed access to internal and external appeals is one of the Affordable Care Act’s consumer protections, fewer than 1% of health plan denials are appealed.⁸ Oftentimes, this is because consumers don’t realize their appeal rights. ⁹

Your doctor will be your ally in the appeals process, and in-network providers will generally submit the paperwork on your behalf.¹⁰ But you’ll want to stay involved in the process, making sure that your health plan has everything needed to conduct the internal appeal, and if necessary, ensuring that everything has been submitted correctly for an external review.

Shopping for new coverage during open enrollment

Medication affordability issues – including denied coverage, step therapy requirements, or increasing out-of-pocket costs – are a reminder to comparison shop for health coverage during open enrollment each year.

If your employer only offers one plan, you may not have any viable alternatives. But if your employer offers multiple options, you can compare them during open enrollment and might find that one of them will provide better coverage for your medications. Employers set their own open enrollment windows, so the dates vary from one employer to another.

If you buy your own health insurance, you’ll likely find plans available from more than one insurer.¹² The annual open enrollment period – Nov. 1 through Jan. 15 in most states – is your opportunity to compare the available plans. The health insurance Marketplace plan comparison tool will allow you to input your prescriptions and will show you the plans that include your medications in their formularies.

If you have Medicare, the annual open enrollment period – Oct. 15 to Dec. 7 – is an opportunity to make changes to your Part D coverage. Medicare’s plan finder tool will allow you to input your medications and will show total out-of-pocket costs under each available plan.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.