My Prescription Drug Isn’t on My Health Plan Drug Formulary. What Now?

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Your health plan's drug formulary doesn't include every prescription your doctor might write. Image &copy: Jeffrey Hamilton/Getty Images

Has your doctor prescribed a drug that your health insurance won’t pay for because it’s not on your health plan’s drug formulary? Do you feel like it should be covered because you really need the drug? Don’t panic; you have some options in this situation.

Start with the simple solutions and work your way up to the more complex solutions. Keep records of what you’ve tried and the outcome of those attempts.

Those records may help you if you choose to request coverage of a non-formulary drug or appeal a health plan decision.

Your Options if Your Rx Drug Isn’t on Your Health Plan’s Drug Formulary

  1. Switch drugs. If your drug is non-formulary because your health plan is steering you to a different drug in the same therapeutic class, this may be a good option. Check with your physician and see if you would be served just as well by a different drug that is on your health plan’s drug formulary.
  2. Pay for it yourself. This is a good choice if the drug is reasonably priced and is non-formulary because it can be obtained over-the-counter or is considered a lifestyle choice. Lifestyle drugs include weight loss drugs, cosmetic drugs, and erectile dysfunction drugs.
  3. Ask your health plan to cover the non-formulary drug as though it were on the formulary. To do this, you’ll need your physician’s help. You’ll have to show why this drug is a better choice for you than the drug of the same therapeutic class that is on the formulary. Try this option if:
    1. You already tried the formulary drug and it didn’t work for you.
    2. You had significant or dangerous side effects with the formulary drug.
    3. There’s a back-order of the formulary drug due to manufacturing problems; you can’t get it.
    4. Your physician feels it would be dangerous for you to make the switch to the formulary drug.
    5. Your physician feels there’s a medical reason why the non-formulary drug is a better option for you.
    6. You’re allergic to the formulary drug.
  1. Apply for help from the drug manufacturer’s patient assistance program. Many drug manufacturers have programs that provide financial assistance to patients who couldn’t otherwise afford particularly expensive drugs. Learn more.

Asking for an Exception to Your Health Plan's Drug Formulary

If you choose to ask your health plan to pay for your prescribed non-formulary drug as though it were on the formulary, you’ll need to show evidence of why this is medically necessary.

Your prescribing physician will have to be involved with this request. It may require faxing letters to your health plan as well as telephone conversations between your health plan’s physicians and your own doctor.

You may need to include copies of your medical records to support your request. You will certainly need to address the issue of why the drug of the same therapeutic class that’s on your health plan’s formulary won’t be a satisfactory substitute.

If you follow your health plan’s process for requesting coverage of a non-formulary drug and your health plan denies your request, you have the right to appeal that denial. If the result of your denial appeal is another refusal to cover your drug, in most cases you have the right to an external appeal. In an external appeal, a neutral third party reviews the appeal and makes a ruling to either uphold the health plan’s earlier denial, or to overturn the denial.

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