At the Pharmacy and Told Your Meds Aren’t Covered? Here’s What to Do Next

 

Ever go to the pharmacy just to find out your medication isn’t covered or the portion of payment you’re responsible for is ridiculously high? You’re not alone. Over one third of Americans have reported that their insurance plan would not cover at least one of their prescribed medications. It’s a common thing that can go wrong at the pharmacy, but is only one of a number of things you may run into during the medication refill process.

If you do have health insurance coverage, here are some issues that could arise at the pharmacy, some tips for how to be prepared, and some possible solutions.

Note: If you don’t currently have insurance coverage, some drug manufacturers offer patient assistance programs (PAPs). They typically apply to people who do not have private insurance, do not qualify for Medicaid, and make less than 400% of the federal poverty level (in 2021, this means if you are a single-person household with less than $51,520 in income or a family of 4 with less than $106,000 in income). If you need coverage for insulin, go to GetInsulin.org to review your best options.

If your insurance does not cover the medication prescribed by your doctor

A thorough doctor will check to see if your insurance covers the medication they’re prescribing, but this isn’t required. If a specific medication is not on your insurance formulary, your doctor may be able to recommend an alternative that could be equally as effective.

As an example, if you need a rapid-acting insulin, each insulin manufacturer makes their own version, but your insurance may only cover one brand (like Humalog, made by Eli Lilly) but not the other (like Novolog, made by Novo Nordisk).

If your body does best on a specific brand of medication that is not covered by your insurance, your doctor may be able to submit a prior authorization (also known as a preauthorization) stating that the prescription is medically necessary (although this does not always work).

If your insurance does cover your medication, but your out of pocket cost is unmanageable

If you aren’t able to get your insurance to cover the medication you need for a reasonable copay, look up the company that makes your medication, and check to see if they offer copay cards.

Copay cards usually apply to people who have insurance, but have a high copay or are responsible for the full cost of the medication because of coverage issues, including being on a high deductible healthcare plan.

Copay cards typically lower your out of pocket cost to $0-$99 per month, depending on the medication. Some can be found through medication coupon resources liked GoodRx (best for medications that are not insulin). If you are specifically looking for coverage for insulin, visit GetInsulin.org to build out a plan of action for the type of insulin you need.

Sometimes, getting your medication through your insurance provider’s preferred pharmacy, particularly a mail-order pharmacy, may help lower cost as well. Often, they will offer a discount if you utilize this option.

Other issues you may run into

Your medication is out of stock

If possible, utilizing auto-refill on the medications you regularly need will help ensure your medication is available when you need it. Otherwise, planning ahead – not waiting until you’re out of a medication to refill it – is always the best bet. But sometimes life gets in the way, so here are some best practices that may help:

  • Call ahead before picking up your medication to make sure that it is in stock and filled.
  • Download your pharmacy’s app on your phone to get alerts if the prescription is out of stock or delayed.
  • Your pharmacy will order more of your medication if it is out of stock, and it will usually arrive the following business day. If you need your medication urgently, ask your pharmacist to check if it is available at other pharmacy locations in the area.
  • If the medication is insulin, you need it now, and your pharmacy is not offering options to help, visit the Urgent Insulin Support page on GetInsulin.org.

It is too soon to refill

Occasionally, your insurance might not refill a prescription because it is “too soon” since the last time you refilled. You may need it sooner due to instances such as you misplaced your medication or the dosage requirements changed.

  • Check with your doctor to see if they can submit authorization to your insurance for an earlier refill for now, and alter how much your are being prescribed to ensure you have enough each month in the longer term.
  • If that doesn’t work, ask your doctor if they can provide you with samples to last you until your next refill.
  • If the medication is insulin, you need it now, and your pharmacy is not offering options to help, visit the Urgent Insulin Support page on GetInsulin.org.

Your prescription expired, but you can’t get ahold of your healthcare provider to renew

If you have an existing prescription at your pharmacy, but have not been able to get ahold of your healthcare provider to renew the prescription, you may be able to take advantage of Kevin’s Law. Kevin’s Law was named for a man with T1D who passed away after not being able to access his insulin prescription over the New Year’s holiday.

Under the law, pharmacists are able to provide an emergency refill of insulin in certain states, without the authorization of a physician to renew the prescription.  Rules around the law vary from state to state and not all states have the law in place. Kevin’s Law only applies to those who have an existing prescription and, depending on where you live, your insurance may or may not cover the refill. Learn more about Kevin’s Law, including whether or not your state has it, here.

Please note, your pharmacist may not know the law by name, or know that the law exists. If you are in a state with Kevin’s Law and working with a pharmacist who is unaware, stay put and ask to speak to someone else in the pharmacy.