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Your doctor prescribes a medication, but your health coverage declines the prescription and now you have to pay the full price without any help from your health insurance.

This growing trend can happen with a new prescription and even a drug you’ve taken for years. This can occur when drug plans change their formularies, which are their lists of covered drugs, from year to year.

Tori Marsh, director of research at GoodRx, says insurance companies have gotten more restrictive with approving drugs and covering prescriptions.

"Just because your formulary covers your medication this year doesn't mean it will next year," says Marsh.

A GoodRx survey found that:

  • 15% of patients said that their insurers have dropped one or more of their prescriptions from coverage in the past year
  • 26% noted that they take one or more medications that aren't covered by insurance

Pharmacy benefits managers (PBMs) work with insurance companies and employer plans to manage drug coverage. When they drop coverage for a drug, it can affect millions of people.

Marsh says that the two largest pharmacy benefit managers -- CVS Caremark and Express Scripts -- manage pharmacy benefits for more than 200 million Americans.

“At the start of 2020, the two companies removed more than 300 medications from their formularies, and they're dropping nearly 200 medications from their formularies for 2021," says Marsh. "Medications no longer covered by one or both PBMs include Accu-Chek products, fluticasone/salmeterol, insulin aspart and Premarin, among others."

If your insurer doesn't cover your medication, you have several options to try to get the drug covered or reduce your costs.

"Ask a lot of questions," says Brian Colburn, senior vice president of Alegeus, which helps employers with their consumer-directed healthcare solutions.

Six things to do if your prescription drug is denied

Here’s what you can do if your prescription drug is denied:

Ask why the drug was denied

Start by asking your pharmacist questions about the denial. Call your insurer to find out why the coverage was denied, recommends Colburn.

"Understand why it's not covered," he says. "Sometimes, there are mistakes."

Also, sometimes it's just a paperwork issue. Insurers often require prior authorization before approving coverage for more-expensive medications. Prior authorization requires your doctor to fill out a form explaining why you need that medication.

The drug may be covered with a letter of medical necessity from your doctor, says Colburn.

Find out if you can use another drug that is covered

A health plan may prefer a different brand or a generic to treat the same condition.

"Typically, other alternative medications may be covered by your plan," says Marsh. "You should always consider talking to your doctor about trying a different medication."

Doctors usually don't know which medicines are covered under your plan's formulary, so it's up to you to ask about other options, says Marsh.

"If you notice that one of your medications has been dropped from coverage or has gotten more expensive, ask your doctor about alternative medications that may be more affordable."

Your insurer or employer may have an online tool that lists similar medications, and you can also find out about alternatives by looking up the drug at GoodRx.com and clicking on "drug info."

Find out about discount programs

You may be able to use a pharmacy discount card to reduce the price significantly, such as from GoodRx or Walgreens. Those discount cards can reduce prescription costs.

Also, ask your pharmacist about any special programs or coupons to reduce the cost or you can search for coupons by typing in the drug name at GoodRx.com.

Make your case to your employer or insurer

You can ask your insurer for an exception if the drug gets dropped from coverage.

"This process requires a supporting statement from your doctor explaining that your drug is medically necessary and that any alternatives would have an adverse effect,” says Marsh.

If that doesn't work, you can file an appeal.

"The exact process will depend on your insurer, but it often requires that you work with your doctor to submit an application or letter of appeal," she says.

If the appeal is denied, you can file for an independent review through your state's insurance regulator, which can take two months to process, she says.

Many large employers self-fund their insurance plans, even though an insurance company administers them. In this case, you can contact your company's human resources department and ask if they'll cover the drug.

When Colburn worked for a previous employer a few years ago, his daughter (who has type 1 diabetes) needed a medication that wasn't covered by his employer's plan. He went to the HR department and explained why she needed the medication, and they ended up covering it.

"Not every employer is going to be like that, and it depends on the medication and whether you feel comfortable talking with them," says Colburn.

Research patient assistance programs

Many drug manufacturers offer discount programs for people based on need -- if there’s no substitute for an on-patent brand name drug that you can’t afford.

You can search for manufacturers' patient assistance programs by looking up your drug. Or you may find resources to help with drug costs at the pharmaceutical company's website.

"Copay card and patient assistance programs are available through pharmaceutical companies to help people that are struggling to afford their medications and can reduce out-of-pocket costs to as little as $0 per month," says Marsh. "Patient assistance programs generally serve the uninsured, while manufacturer copay cards are for those with insurance."

GoodRx has a database of copay cards of over 700 medications. To find one, search the name of the drug on GoodRx.com and scroll down to see if there is a copay card for your drug under "ways to save."

Several charitable foundations have programs that can also help, which you can find through the Patient Access Network (PAN) Foundation. You can search for help from state and local pharmaceutical assistance and other programs at the National Council on Aging's BenefitsCheckup.org.

Find resources through an advocacy organization for your disease

Many people with a similar condition may have the same trouble getting coverage for their medications. Organizations focusing on the disease often have great resources to help you find assistance.

For example, the American Diabetes Association has a resource page for information about getting help paying for insulin and diabetes medications from several manufacturers. The Arthritis Foundation has a list of consumer assistance programs to help with medical and drug costs.

Having your medication declined is becoming more common. Following these steps may get the plan to change its decision or you may find ways to cut your drug costs.