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What can I do if my drug is not on my plan’s drug list?

It is best to pick a plan that has all or most of your drugs on its drug list or formulary.  When you go to pick a plan, you may see that some plans cost more because they do not have your drugs on the list. Or you may get a prescription later that isn't covered by your current plan's drug list.

If you find that one of your drugs is not covered, the first thing you should do is contact your plan to ask why. Your plan should have a toll-free phone number you can call to get this information. The toll-free number should be listed on your plan ID card.

There are a couple of reasons why your plan may not cover the drug you need:

  • the drug is not on your plan's list of covered drugs, also called the formulary
  • the plan may have special rules or set limits on how you get your drugs

If either of these things happens, you have some options. You can:

  • talk with your doctor to see if you can switch to a similar drug that is on your plan's formulary, or list of covered drugs, OR
  • Pay full price for the drug (however, your costs for this drug will not count toward your out-of-pocket costs), OR
  • Ask your plan for what is called an exception.

NOTE: Your plan must make sure that you can get the drugs you need.

There are a number of ways your drug plan can help you switch or “transition” your drugs to the new plan.

They can give you a 30-day supply of the drug. This gives you and your doctor time to either

  •  Switch you to one of the drugs the plan covers, or
  • Ask for an exception so that your plan will cover your drug.

You can get this 30-day supply only if you already had a prescription for the drug. It does not apply to new prescriptions.

How do I ask for an exception?

You must call or write your plan and ask for the exception or special permission. Your doctor must also send a statement. It must say that the prescription drug you have asked for is medically necessary to treat your disease or condition. The plan would need to know what other drugs you've tried, how they worked, and how this one is working.

Learn more about asking for an exception.

Can I pay less or get a higher dose?

You may ask if you can get a drug at a lower co-pay. This is important if your drug has a high co-pay. You may also ask if you can get more pills or a higher dose each month.

How long will it take for a decision?

The plan must let you know if it will cover the drug or if it will change your co-pay within 72 hours. If your doctor believes that waiting 72 hours for the drug is a risk to your health, the plan must let you know in 24 hours or less.

If my plan agrees to cover my drug, do I have to ask for an exception every time I get a refill?

No, once the plan says it will cover your drug, give you the amount you asked for, or give you a lower co-pay, you should get the drug under those terms for the rest of the enrollment year.  You should not need to ask again for the same drug.

NEXT: Which drugs must all plans cover?

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