You finally get the prescription you need, take it to the pharmacy, and then hear the words nobody wants to hear:
“Your insurance won’t cover this medication.”
Maybe the medication requires prior authorization. Maybe your insurance company wants you to try another drug first. Maybe the medication simply isn’t on your plan’s formulary. Or perhaps the insurer says the medication isn’t medically necessary.
Whatever the reason, an insurance denial does not necessarily mean you have to go without your medication.
There are several steps you can take and depending on your situation, there may be ways to get the medication covered or find assistance with the cost.
Here’s what to do next.
First: Find Out Why Your Prescription Was Denied
Don’t immediately assume that “denied” means “never.”
Insurance companies use different coverage rules for prescription medications. Your denial may be related to:
- Prior authorization: Your doctor needs to provide additional information before the insurer will approve the medication.
- Step therapy: Your plan requires you to try another medication first, usually a lower-cost alternative.
- Formulary restrictions: The medication isn’t included on your plan’s covered drug list.
- Quantity limits: Your plan limits how much of the medication it will cover within a certain period.
- Medical necessity: The insurer wants additional documentation explaining why the medication is medically necessary.
- Coverage exclusions: Your specific plan may not cover the medication at all.
The first thing to do is ask your insurance company for the specific reason for the denial.
Don’t settle for “it’s not covered.” Ask:
“Why was this medication denied, and what do I need to do for it to be covered?”
That answer can determine your next step.
Step 1: Talk to Your Doctor’s Office
Your doctor’s office may be able to help resolve the problem.
Depending on the reason for the denial, your doctor may be able to submit a prior authorization, provide additional medical records, explain why the medication is medically necessary, or request an exception to your plan’s coverage rules.
In some cases, your doctor may also be able to recommend an alternative medication that your insurance covers.
Don’t assume that your doctor’s office has already done everything possible. Call and ask:
“Can your office appeal the denial or submit a prior authorization for this medication?”
For certain insurance plans, your doctor may need to provide a supporting statement explaining why the medication is medically necessary or why alternatives aren’t appropriate.
Step 2: Ask About an Exception
If your insurance plan normally doesn’t cover the medication, you may still be able to request an exception.
An exception can be particularly important when the medications your plan normally covers aren’t appropriate for your situation.
For example, your doctor may be able to explain that:
- You previously tried another medication and it didn’t work.
- You experienced unacceptable side effects from another medication.
- Your medical condition requires a specific treatment.
- Another covered medication would be less effective for you.
The exact rules depend on your health plan, so ask the insurer what type of exception is available and what documentation is required.
For Marketplace plans, HealthCare.gov confirms that consumers have the right to use their plan’s drug-exception process in certain circumstances and may appeal if an exception is denied.
Step 3: Appeal the Insurance Company’s Decision
An insurance denial isn’t necessarily the final decision.
If your health plan refuses to cover a medication or treatment that you believe should be covered, you generally have the right to appeal the decision. Depending on your coverage, this can involve an internal appeal and potentially an external review by an independent third party.
Your denial notice should explain:
- Why the claim or medication was denied
- How to appeal
- Where to send the appeal
- The applicable deadline
- Whether an expedited appeal is available
Keep every document.
Save the denial letter, your doctor’s supporting documentation, pharmacy communications, appeal forms, and notes from conversations with your insurance company.
It can also help to write down:
- The date you called
- The name or ID of the representative
- What you were told
- Any reference or case number
- What you were instructed to do next
If you’re dealing with an urgent medical situation, ask whether you qualify for an expedited appeal. Certain plans provide faster review when waiting for the standard process could seriously jeopardize your health.
Step 4: Don’t Forget About Prescription Assistance
Here’s an important point many people overlook:
You don’t necessarily have to choose between insurance and prescription assistance.
If your insurance won’t cover a medication or your out-of-pocket cost is still unaffordable it may be worth investigating prescription assistance programs.
Depending on the medication and your circumstances, assistance may be available through:
- Pharmaceutical manufacturer patient assistance programs
- Other prescription assistance programs
- Discount programs
- Manufacturer savings programs
- Nonprofit assistance organizations
- Other legitimate medication-cost resources
Eligibility varies significantly from one program to another.
Some programs consider factors such as income, insurance status, diagnosis, residency, and the specific medication being requested.
That’s why it’s important to look at the specific program requirements rather than assuming you won’t qualify.
What If You Need the Medication Right Now?
This is where things can become especially stressful.
If you’ve run out of medication or are concerned about going without it, don’t simply stop taking a prescribed medication without talking to your doctor or pharmacist.
Ask your healthcare provider or pharmacist what options are available while the coverage issue is being resolved.
Depending on the medication and your insurance plan, there may be options such as:
- A temporary supply
- A covered alternative
- A prior authorization
- An exception request
- An expedited appeal
- A manufacturer assistance program
- Another legitimate way to reduce the immediate cost
For some Medicare drug plans, for example, certain situations may qualify for a transition supply when a medication isn’t covered or requires a coverage rule such as prior authorization or step therapy.
Your specific options will depend on your plan and medication.
What If Your Insurance Says You Have to Try Another Drug First?
This is commonly called step therapy.
Your insurance company may require you to try a lower-cost medication before it will cover the medication your doctor originally prescribed.
That doesn’t necessarily mean your doctor’s prescription is wrong.
If your doctor believes the preferred medication is medically necessary, ask whether the doctor can request an exception and explain why the alternative isn’t appropriate for you.
Medicare describes step therapy as a coverage rule requiring a patient to try a different medication before moving to another medication covered by the plan.
What If You Have Medicare?
Medicare beneficiaries have their own prescription drug appeals process.
If a Medicare drug plan refuses to cover a medication, you can request a coverage determination and, when appropriate, an exception. If the decision is unfavorable, you may have additional levels of appeal available.
For Medicare drug plans, the initial appeal is generally called a redetermination, and additional levels of review may be available if the denial is upheld.
Because Medicare rules and deadlines can be specific, carefully review the denial notice and your plan’s instructions.
What If You Have Marketplace Insurance?
If you have health insurance through the Marketplace and your insurer denies coverage, you generally have appeal rights.
HealthCare.gov explains that consumers can request an internal appeal and, in eligible situations, an external review by an independent reviewer.
You can also seek assistance through your state’s Consumer Assistance Program or Department of Insurance if you need help understanding or pursuing an appeal.
The Most Important Thing: Don’t Give Up After the First “No”
A prescription denial can feel like the end of the road.
It isn’t always.
The denial may simply mean that another step is required before the medication can be covered.
Your next move should be to determine why the medication was denied, work with your doctor to address the issue, understand your appeal rights, and investigate legitimate prescription assistance options if the medication remains unaffordable.
A Simple Prescription Denial Checklist
If your prescription was denied, work through this list:
1. Ask why it was denied.
Get the specific reason not just “it’s not covered.”
2. Check your plan’s requirements.
Find out whether prior authorization, step therapy, quantity limits, or an exception applies.
3. Contact your doctor’s office.
Ask whether they can submit additional information or appeal the decision.
4. Ask about an exception.
Your doctor may be able to explain why another medication isn’t appropriate.
5. File an appeal if appropriate.
Follow the instructions and deadlines in your denial notice.
6. Investigate prescription assistance.
If insurance still won’t cover the medication or the cost remains too high look for legitimate assistance programs.
7. Don’t stop medication on your own.
Talk to your doctor or pharmacist about what to do while you’re resolving the coverage problem.
Affordable Medication May Be Closer Than You Think
Getting a prescription denied can be frustrating, confusing, and expensive. But a denial doesn’t automatically mean you have to pay the full retail price or go without the medication your doctor prescribed.
There may be appeals, exceptions, alternative coverage options, or prescription assistance programs worth exploring.
At Affordable Prescription Assistance, our goal is to help people better understand their options when the cost of prescription medication becomes a barrier.
If you can’t afford a medication, don’t assume there are no options.
Start by finding out what’s available to you.
Because getting the prescription is only half the battle. Being able to afford it matters, too.