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Help! My drug is no longer covered by my insurance company. What can I do?

Consumer Reports News: June 06, 2013 10:08 AM

You have a few choices: Ask your doctor to prescribe a different drug from your insurance company's formulary. If that's not possible or your doctor says it's not a good idea, have your doctor petition your insurance company to cover the drug. If your health plan denies your request, you can file an appeal.

Some commercial plans, as well as Medicare Part D and Advantage plans, have preferred, retail pharmacies. Check with your plan to make sure you are using one of those in order to get the best price. Using your plan's mail order service may also help you save money.

Your pharmacist may also be able to help. "We can work with patients to choose a different drug that's affordable, find a generic substitute, or go through the prior authorization process to petition the plan," Tim Davis, Pharm.D., owner and pharmacist of Beaver Health Mart Pharmacy in Beaver, Penn.

Virtually every drug coverage plan has a formulary, which is a list of drugs that the company covers. You'll get the lowest out-of-pocket costs or co-pay when you buy the coverage plan's "preferred" generic drugs. Another category, "acceptable" generic drugs are slightly more expensive, followed by preferred brand-name drugs, then acceptable brand-name drugs. Drugs that aren't listed on the formulary will have the highest out-of-pocket costs or simply won't be covered. Drugs that are usually not covered on formularies include those used for cosmetic, sexual dysfunction, weight-loss, or experimental purposes.

Among typically covered drug classes, insurance and drug-benefit companies select medications based on safety, effectiveness, and cost. Although price is often a consideration, companies may choose to list more expensive drugs when drug manufacturers offer the insurer or drug-benefit firm large rebates.

Up to 10 percent of consumers nationwide learn, at one time or another, that a drug they've been prescribed is no longer covered, says Stephen W. Schondelmeyer, Pharm.D., Ph.D., professor of pharmaceutical economics at the University of Minnesota College of Pharmacy, and many people don't know it's a possibility until it happens.

Formularies can change several times per year, so a drug that's been covered before may not remain on the list. Why? Relationships between insurance companies and drug manufacturers can change, and that can affect the availability or price of certain medications. Medicare Part D and Advantage plans usually must notify you 60 days in advance if a drug you're taking will no longer be covered.

Lisa Fields


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