Can I switch to a different ACA plan if my medications aren’t covered?

What can I do if the prescription drugs I need aren’t covered by my ACA plan?

If the prescription drugs you need aren’t covered by your ACA health insurance plan, you still have several options to explore. Insurance companies have a list of covered medications called a formulary, and sometimes a drug you need may not be included in this list. Here’s what you can do if you find that your medication isn’t covered:

1. Check for Alternative Medications

The first step is to discuss with your doctor whether there are alternative medications that are covered by your plan’s formulary. Your doctor may be able to:

• Prescribe a generic version of your medication, which is typically more affordable and often covered by most plans.

• Recommend a preferred brand-name drug that is similar to the one you need but is covered under your plan’s formulary.

Generic drugs and preferred brand-name drugs in lower tiers often have lower out-of-pocket costs and may be suitable alternatives to non-covered medications.

2. Request a Formulary Exception

If your doctor believes that the non-covered medication is medically necessary and there are no suitable alternatives, you can request a formulary exception from your insurance company. This process asks the insurer to cover the drug that isn’t normally included in the plan’s formulary.

To request a formulary exception:

• Your doctor will likely need to provide a letter of medical necessity, explaining why the medication is essential for your treatment.

• Your insurer will review the request, and if approved, your medication will be covered at a rate similar to other medications in the formulary.

3. File an Appeal

If your request for a formulary exception is denied, you can appeal the decision with your insurance company. Here’s how to proceed:

• Internal appeal: You can ask your insurance company to review the denial. This requires submitting additional documentation, usually from your doctor, to explain why the medication is medically necessary.

• External review: If your internal appeal is denied, you have the right to request an external review by an independent third party who will determine whether the insurance company must cover the medication.

Appeals can take time, but they offer a path to getting coverage for non-formulary medications if medically necessary.

4. Explore Discount Programs or Manufacturer Coupons

If your medication isn’t covered and you cannot get a formulary exception, you may be able to reduce costs by using pharmacy discount programs or manufacturer coupons. Some options include:

• Pharmacy discount cards (such as GoodRx or SingleCare), which offer discounts on a wide range of prescription medications.

• Manufacturer assistance programs: Many pharmaceutical companies offer discounts or coupons for their medications, especially for brand-name drugs.

These programs may significantly lower your out-of-pocket costs for non-covered medications.

5. Check for State or Federal Assistance Programs

Depending on your income and circumstances, you may qualify for additional assistance through state or federal programs, including:

• Patient assistance programs (PAPs): These programs, often sponsored by drug manufacturers, provide free or discounted medications to eligible individuals.

• Medicaid: If your income is low, you may qualify for Medicaid, which can offer additional coverage for prescription drugs not covered by your ACA plan.

6. Switch to a Different Health Insurance Plan

If your medication is essential and not covered by your current ACA plan, you may want to consider switching to a plan that better suits your prescription needs. During the Open Enrollment Period (or if you qualify for a Special Enrollment Period), you can:

• Review other ACA plans on the marketplace and compare their formularies to see which one covers your medication.

• Choose a plan that offers the coverage you need, factoring in both the premium costs and out-of-pocket costs for prescription drugs.

Key Takeaways:

• Request a formulary exception or appeal if your medication isn’t covered and your doctor believes it is medically necessary.

• Check for alternative medications that are covered by your plan’s formulary, such as generics or preferred brand-name drugs.

• Explore discount programs, coupons, or patient assistance programs to lower costs for non-covered medications.

• Consider switching to a different ACA plan during Open Enrollment if your current plan doesn’t meet your prescription needs.

For help with formulary exceptions or understanding your coverage options, schedule an appointment with a Tsunami Advisor here: Schedule an Appointment.