By Patricia Prewitt
My Personal Rx Adviser
We are all unique individuals, and each of us will respond to prescription medications differently. It can be quite frustrating to find a product that works well, only to discover that the medication is not covered.
Here are the top five reasons why a prescription may not be covered:
- Lifestyle categories: Medications considered “lifestyle drugs,” such as for sexual function (like Viagra), hair growth, acne or anti-aging (cosmetic use), and weight loss are typically considered “not medically necessary” and are often excluded from insurance carriers drug formularies.
The full retail costs are typically paid by the patient to obtain the prescription. Prices can vary greatly among retail outlets. This is definitely the time to compare prices at different pharmacies. Check out saving card offerings. - New to the market: It takes at least 6-12 months or longer for a new product to gain formulary acceptance with insurance plans. Companies wait for real-world experience to be reported before adding a new drug to their formulary and negotiate with the manufacturer for tier placement and incentives.
Once FDA approvals are in place, companies may give “free trial” cards to medical offices, encouraging clinicians to try the new product for appropriate patients. If a provider wants to try a new medication for your medical problem, ask if they have a “trial coupon” you might use. The trial may be for only a few days or as long as one month. Sometimes samples will be available – just ask! - Deductibles: You may not have met your drug plan and/or insurance plan deductible, which can be significant. Until that is met, prescription costs will be significant for any brand-name medications, and can add up for higher cost generics, too. For brand-name medications, search the website for brand offerings. Using a copay card may help to save out-of-pocket costs and may accrue to your deductible.
- Generic alternatives: When a lower-cost generic is available, insurance plans often refuse to cover the higher-cost brand. This can be a logical policy, unless the generic version uses dyes or has ingredients problematic for the patient. If you have a problem with side effects for the approved generic, ask your clinician to document the allergy or problem with the generic version, then request a special exemption for coverage.
- Unapproved Use: Plans reserve the right to deny coverage of a prescription when it is being used “off label,” i.e. for something other than its indication. The diagnosis needs to match the labeling for its approved use. The clinician may be able to make a case for your prescription plan to cover a product. This takes a lot of time, effort, and documentation for an appeal. Often, the patient is required to cover the costs of treatment to continue the therapy.
Always check for savings cards or options on the manufacturer’s website if the product is an expensive, brand-name patented product.
Content provided is for educational purposes only, and is not intended as a substitute for advice from a qualified medical professional. The opinions expressed within are those of the author.
About the Author: Patricia Prewitt is a local Massachusetts resident who spent more than 30 years in the pharmaceutical industry. Tricia is a consumer education advocate, and loves helping people find ways to save money on their prescriptions. More information and free resources are available on her website at https://mypersonalrxadvisor.com/resources or call her at 508-507-8840. Favorite Quote: “Act as if what you do makes a difference. It does.” – William James
