Key takeaways:
- Insurance companies don’t cover some medications, which often leaves consumers responsible for the full costs.
- If your prescription is not covered, you can try generics, biosimilars, or other alternatives. You also may qualify for patient assistance and manufacturer copay programs that can help you cover costs.
- If an insurance company won’t cover your medication, you can ask for an exception. If that doesn’t work, you can appeal the coverage decision.
It’s frustrating when your health insurance won’t cover your medication. Often, a drug appears on a formulary — the list of medications covered by an insurance plan — but then gets dropped. This can happen if a medication is seldom used, there is a generic or biosimilar available, or a more affordable option exists. Whatever the reason, you’re stuck with the full cost despite having coverage for prescribed medications.
Here’s what you can do if your prescription medication is not covered.
What to do when your medication isn’t covered
If you find out that your insurance provider won’t pay for a new prescription or they stop covering a medication you already take, you can explore these options.
1. Talk to your doctor about alternatives
Your doctor has no obligation to weigh costs when prescribing your medications and almost certainly won’t know which medications are covered under your insurance plan’s formulary. That’s why it’s up to you to raise concerns about cost.
If one of your medications has been dropped from coverage or has gotten more expensive, ask your doctor about generics and alternative medications, such as biosimilars for biologics, which may be more affordable. You may also find a lower price for the prescription with GoodRx.
If you can’t find a lower-cost option that works for your condition and your budget, your doctor still may be able to help you. Try:
- Requesting a 90-day prescription and comparing costs; getting a 3-month supply may be a better value than filling monthly.
- Getting a prescription for a higher-dose pill; ask your doctor and pharmacist if the medication will work if you cut a pill or dose in half to save money.
- Asking for free samples of the medication.
2. Ask for an exception from your prescription plan
If you and your doctor can’t find an affordable option together, speak with your insurer about making a formulary exception and providing coverage for your drug. Your doctor will most likely need to submit a supporting statement (sometimes called a letter of medical necessity) explaining that your drug is medically necessary and that any alternatives would have an adverse effect.
Note: Some plans will require that you agree to “step therapy” before approving your exception. Step therapy is a type of prior authorization that requires you to:
- First, try a less-costly medication that’s on the plan’s formulary.
- Second, prove that it’s not effective for you or has adverse effects.
- Then move up a “step” to the medication you’re requesting.
- Save on meds. Choosing an insurance plan that covers your medications, participating in step therapy, and using manufacturer copay cards can help you make prescriptions more affordable.
- There’s a ‘Big Pinch’ on consumers. Prescription plans are covering fewer medications and adding restrictions, which means you’re paying more out of pocket.
- Your state may be trying to reduce the cost of your meds. Prescription drug affordability boards have been created in 11 states to reduce the cost of medication.
If the medication you need is on your plan’s formulary, but it’s on a high tier or is non-preferred, you can still ask your insurer for an exception (high-tiered or non-preferred medications will cost you more out of pocket). If you’re approved, this “tier exception” will help lower your out-of-pocket costs.
3. Apply for a patient assistance program or manufacturer copay program
Patient assistance programs and manufacturer copay programs help people save on specific medications — particularly costly, brand-name ones that are often not covered by insurance. These programs can reduce out-of-pocket costs to $0 per month for people with and without insurance. Keep in mind: Patient assistance programs generally serve the uninsured, while manufacturer copay programs are for those with insurance.
You can typically find these programs on the websites of the drug manufacturers. The companies often have partnerships with related company foundations or other nonprofit organizations that connect people in need with deeply discounted or free medication.
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Here are some examples of programs that can help you afford your medications:
- AstraZeneca: The AZ & Me AstraZeneca Prescription Savings Program can help you get free medication. You are eligible if you don’t have health insurance or if you have Medicare but still can’t afford your prescriptions. There are also income requirements. AstraZeneca makes many medications, including Farxiga, which is used for Type 2 diabetes and other conditions, and Tagrisso, which treats lung cancer.
- Janssen CarePath: The savings program known as Janssen CarePath is transitioning to become J&J with Me. For a while, you’ll see both names used. This savings program includes more than 40 medications, including Remicade, Simponi, and Stelara, all of which treat autoimmune conditions. There are no income requirements. The Janssen CarePath Patient Assistance Program is for people who have insurance. There are income requirements.
- Lilly Cares: The Lilly Cares Foundation Patient Assistance Program helps people in financial need access more than two dozen medications at no cost. Eligible medications include several insulins in different formulations — such as Humalog and Humulin R, as well as Cymbalta, which treats conditions including depression, anxiety, and long-term pain.
- Merck: MerckHelps assists people in affording their medications through several programs, such as the Merck Patient Assistance Program and the Merck Vaccine Patient Assistance Program. MerckHelps also has a program to replace certain medications you received in the hospital. You may be able to get medications at no cost, including Keytruda, which treats many types of cancer, and Januvia, for Type 2 diabetes.
You can also find these programs through GoodRx. Just search for your medication on GoodRx.com and scroll down to find information about ways to save.
4. Reconsider your health plan during an enrollment period
If your plan no longer covers your prescription medication, find a plan that has the medication on its formulary. If you are enrolling in original Medicare or a Medicare Advantage plan, be sure to use the Medicare Plan Finder tool to identify a Medicare Part D prescription drug plan that covers the medications you need.
How to file an appeal for prescription drug coverage
If you have explored other options for lowering your prescription costs with no luck, you can file an internal appeal with your insurance plan. The exact process will depend on your insurer, but it often requires that you:
- Complete all forms required by the insurance plan.
- Submit any information you want considered, such as a letter from your doctor explaining that the medication is medically necessary.
If you need help, contact the consumer assistance program in your state. If you are enrolled in Medicare, you can also get free help from a State Health Insurance Assistance Program (SHIP) near you.
If your appeal is for a medication you haven’t started taking yet, the insurer must complete the internal review within 30 days. If it’s for a medication you’ve already started taking, the review must be completed within 60 days. In urgent situations, you can request an expedited appeal. In expedited cases, a final decision must be made as soon as required by your medical condition or within 4 business days.
What if your insurance plan denies your appeal for drug coverage?
If your insurance plan denies your appeal, try filing for an independent review through your state’s insurance regulator as a last resort. The process can seem daunting, but the odds are in your favor because many appeals get approved.
The independent review can take up to 60 days. If your state doesn’t have an external review process, the U.S. Department of Health and Human Services (HHS) or a private review organization will oversee the case. Your review won’t cost anything if HHS handles it, but it may cost $25 through your state or a private review organization. If you urgently need the medication, you can request an external review before the internal review is complete.
Where can I find more information on medication appeals?
If you’d like more information on the appeals process, check out these sites:
- HealthCare.gov has more information on navigating the appeals process.
- The Patient Advocate Foundation has tips on how to write and submit an appeal.
- The Centers for Medicare & Medicaid Services, known as CMS, has tips on how to write and submit an appeal if you’re on Medicare.
- The National Association of Insurance Commissioners has information on how to contact your state insurance regulator.
Frequently asked questions
A non-formulary drug doesn’t appear on your insurance plan’s formulary — or the list of covered medications. This typically happens when there is a generic version available or if your prescription plan prefers a similar medication deemed safer and more effective. A non-formulary drug is not covered, but you can ask for an exception so that your medication may be covered.
The bottom line
Don’t panic if your insurance company won’t pay for your medication. There are steps you can take to reduce out-of-pocket costs for your treatment and possibly get the decision reversed.
First, see if there’s a generic or lower-cost medication that will work for you. You also may qualify for a patient assistance or copay assistance program that can reduce your out-of-pocket costs. If neither of these options works, you can ask the insurance company for an exception to the formulary so that your medication may be covered. If you’re still stuck, formally appeal the decision with an internal review. As a last resort, seek an external appeal. Remember that every objection to your insurance company will require a letter of medical necessity from your doctor.
Why trust our experts?
Tamara E. Holmes
Cindy George, MPH
Our editorial standardsMeet our expertsReferences
Centers for Medicare & Medicaid Services. (2023). Consumer assistance program.
Centers for Medicare & Medicaid Services. (2024). HHS-administered federal external review process for health insurance coverage.
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