Danya Institute Inc.

What To Know About Getting Your Prescription Medications

Health plans will help pay the cost of certain prescription medications. You may be able to buy other medications, but medications on your plan’s “formulary” (approved list) usually will be less expensive for you.

Does my new insurance plan cover my prescription? 

To find out which prescriptions are covered through your new Marketplace plan:

Visit your insurer’s website to review a list of prescriptions your plan covers.
See your “Summary of Benefits and Coverage,” which is also available in I Apply” on HealthCare.gov.

Call your insurer directly to find out what is covered, and have your plan information
available. The number is on your insurance card, the insurer’s website, and HealthCare.gov.
Review any coverage materials that your plan mailed to you.

I’m at the pharmacy to pick up my prescription, and they said my plan no longer covers it. What do I do? 

Some insurers may provide a one-time refill for your medication after you first enroll. Ask your insurer if they offer a one-time refill until you can discuss next steps with your doctor.

If you can’t get a one-time refill, you have the right to follow your insurer’s drug exceptions process, which allows you to get a prescribed drug that’s not normally covered by your health plan. Because the details of every plan’s exceptions process are different, you should contact your insurer for more information.

Generally, to get your drug covered through the exceptions process, your doctor must confirm to your health plan (orally or in writing) that the drug is appropriate for your medical condition based on one or more of the following:

• All other drugs covered by the plan haven’t been or won’t be as effective as the drug you’re
• Any alternative drug covered by your plan has caused or is likely to cause side effects that
may be harmful to you

• If there’s a limit on the number of doses you’re allowed:
o That allowed dosage hasn’t worked for your condition, or
o The drug likely won’t work for you based on your physical or mental makeup. For
example, based on your body weight, you may need to take more doses than what’s
allowed by your plan.

If you get the exception:

• Your health plan generally will treat the drug as covered and charge you the copayment
that applies to the most expensive drugs already covered on the plan (for example a non-preferred brand drug)

  • Any amount you pay for the drug generally will count toward your deductible and/or maximum out-of-pocket limits.

 Can I get the non-covered drug during the exceptions process? 

• While you’re in the exceptions process, your plan must give you access to the requested drug until a decision is made.

My insurer denied my request for an exception. Now what do I do?
If your health insurance company won’t pay for your prescription, you have the right to appeal the decision and have it reviewed by an independent third party. To learn more about the appeals process, read “Appeals: eligibility and health plan decisions in the Health Insurance Marketplace.”

Can I go to my regular pharmacy to get my medication?
Just like different health plans cover different medications, different health plans allow you to get  your medications from different pharmacies (called “in-network pharmacies”). Call your insurer or visit their website to ind out whether your regular pharmacy is in-network under your new plan and, if not, what pharmacies in your area are in-network. You can also learn whether you can get your prescription delivered to you in the mail.

If you have additional questions, call 1-800-318-2596. TTY users should call 1-855-889-4325.


For more information please visit: http://marketplace.cms.gov/getofficialresources/publications-and-articles/getting-your-prescription-medications.pdf