By Patricia Prewitt

My Personal Rx Adviser

Most of us have received the dreaded notification that a medication is “no longer covered” on our insurance plan. Often this occurs at the beginning of the year, or mid-year when formulary committees evaluate utilization and cost to benefit ratios.

How do insurance companies decide which medications they will cover?

Each year, insurance companies evaluate which products to cover on their formulary list. Rules exist to ensure that each carrier offers at least two medications for major therapeutic areas.

Why do insurance companies change the products they will cover?

It could be that the plan has negotiated a more favorable price or incentives with a competitor product. Sometimes, certain types of medications may be dropped from the plan altogether.

Here in Massachusetts, many of the insurance carriers stopped covering the newer GLP-1 medications for weight loss in 2026, leaving people searching for alternative ways to continue on GLP-1 therapy. Some insurance plans may continue to cover these medications, but only for specific usage cases and significant medical conditions.

What can I do if my prescription insurance plan stops covering my medication?

The easiest course of action is to accept the change when an alternative product is offered by the plan.

What if I had side effects or am allergic to the alternative product they suggest?

Your medical provider has probably noted a treatment failure on therapy in your chart. Having documentation can be a key element in your favor for obtaining what’s called a “prior authorization” to request continuation of insurance coverage for the medication that works well for you.

Are there tactics a medical office uses to obtain an approval?

Many medical offices use a digital tool called Cover My Meds to argue why the specific medication is needed.

What can I do to help my provider get the medication approved?

Tell your doctor about all of the medications you have tried, along with the side effects experienced. Explain why this medication matters to you in terms of cost, and effectiveness.

I’ve heard that obtaining approvals is difficult, and often takes a long time. Is that true?

No question, this is an administration burden. Digital tools can help to streamline the process, but approvals will take a few days or longer. Insurance companies often request even more documentation-appeals after initial denials are common.

Is it worth fighting for prior authorization for a needed medication if I am a Medicare subscriber?

For Medicare subscribers, an approval may translate to better health and save money. I’ve seen a client push for insurance approval – the physician was able to document a medical necessity. The prescription was approved at a $625 monthly cost to the patient. Expensive? Yes! However, due to the 2026 Inflation Reduction Act rules, the maximum Medicare annual out-of-pocket costs for approved prescriptions is capped at $2,100 per year. This threshold will be reached in less than four months, with the prescription plan covering costs until the end of 2026.

The alternative source at $499 a month, (lower than $625) would translate to nearly $6,000 out-of-pocket annually, none of which is covered by insurance. Health needs and prescription plans are unique to each person, so always confirm what works best for your health and wallet.

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