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Use Your Plan: Troubleshooting

Problem #5: Your health plan does not pay for the medicine you were prescribed.

It may be that the medicine prescribed by the doctor is not covered by your health plan, or is not on the formulary, the list of medicines covered by the plan. You can usually find the list of covered medicines on your plan's Web site or by calling the member services phone number on the back of your pharmacy ID card. If this is the problem, you can either pay for the medicine yourself or ask your doctor if a different medicine—one your insurance will pay for—will work for you. If not, you or your doctor can ask your health plan how you can still get the medicine covered. Many plans will approve coverage of a non-formulary medication if your doctor requests an exception based on medical necessity. If that fails, you may need to make a formal, written appeal to request that the insurance company make an exception to its policy and cover the medicine.