If you’re unable to watch the video above, you may read the video transcript below.
To find out which drugs your insurance plan covers, visit your insurer’s website to review a list of covered drugs, check your “Summary of Benefits and Coverage,” call your insurer directly to find out what’s covered, or review your coverage materials sent to you by your plan.
Health plans help pay the cost of certain prescription drugs. Keep in mind, drugs on your plan’s “formulary,” or drug list, usually will be less expensive for you.
So what happens if you’re at the pharmacy to pick up your prescription, and they say your plan no longer covers it?
First, ask your insurer if they offer a one-time refill until you can discuss next steps with your doctor; some insurers may give a one-time refill upon first enrolling.
If you can’t get a one-time refill, follow your insurer’s drug exceptions process. This process allows you to get a prescribed drug that’s not normally covered by your health plan. While you’re going through the exceptions process, your plan must give you access to the drug you and your doctor asked for until a decision is made. Please note, every plan’s exceptions process is a little different so you should contact your insurer for more information.
To get your drug covered through the exceptions process, it is usually required that your doctor confirm that the drug is appropriate for your medical condition based on one or more conditions – Either all other drugs covered by the plan haven’t been or will not be as effective, any alternative drug covered by your plan has caused or is likely to cause side effects that may be harmful to you, or there is a limit on the number of doses you are allowed. Your doctor should submit this confirmation to your health plan either in writing or over the phone.
If you get the exception, your health plan will normally treat the drug as covered and charge you the copayment that applies to the most expensive drugs already covered on the plan. Any amount you pay for the drug will typically count toward your deductible and/or maximum out-of-pocket limits.
In the end, if your health insurance company won’t pay for your drug, you have the right to appeal the decision and have it reviewed by an independent third party. Review the materials provided to you by your health plan to learn more about the appeals process.
Just like your doctor’s visits, staying in-network to get your prescription drugs is important. Call your insurer or visit their website to find out whether your regular pharmacy is in-network and, if not, what network pharmacies are in your area.
HealthTN takes pride in assisting beneficiaries in navigating their health care needs. While the core reason many purchase insurance has not changed, the process has. Our agents are trained in multiple plans to help you find the health insurance that best fits you! Visit HealthTN.com today.