6 Ways Your Insurer May Prevent You from Getting Your Medicine

There are barriers that insurers may impose preventing you from accessing the medicines you need. Knowing what your plan includes and what the barriers are ahead of time can help you ask the right questions and look for coverage that works best for you. Here are some key things to know:

1. Prior Authorization

Your insurer may require your doctor to obtain approval from the insurance company before they will cover a medicine. This process can often be burdensome and time consuming, potentially causing delays in access to needed treatments, which in turn may negatively affect your overall health.

2. Step Therapy ("Fail First")

Your insurer may require you to demonstrate that other medicines on your plan’s preferred drug list (also known as a formulary) don’t work for you before they agree to cover the cost of the original medicine your doctor prescribed.

3. Non-Medical Prescription Swapping

Your insurer can require you to switch to another medicine, even if your current medicine is working or the other medication is different from your doctor’s prescription. Insurers do this by changing which medicines are covered on their formulary or by requiring patients to try alternative medicines first, a.k.a. step therapy. In some cases, patients who are required to switch medicines for non-medical reasons may not respond to the new therapy or may have an adverse reaction.

4. High Out-of-Pocket Costs

Insurers are increasingly imposing higher cost sharing for medicines for patients, especially when compared to other health care services. These costs may come in the form of a deductible (the amount you have to pay before your insurance will start covering most expenses), a co-pay (a fixed cost you may have to pay when you visit the doctor or pick up a prescription medicine, once you’ve met the deductible) or coinsurance (a percentage of the total cost you may have to pay to pick up a prescription medicine once you’ve met the deductible).

5. Not Covered at All

Insurers can limit the medicines they cover by placing only some of them on a formulary. Finding out if the medicines you need are covered before you pick a plan is critical, but sometimes that information can be hard to find. Call insurance plans directly to get a copy of a plan’s formulary (or list of covered medicines), find out if the medicines you need are covered and ask what you’ll have to pay for them at the pharmacy. If you find out that a medicine is not covered and you are not able to switch plans, you can ask to go through an exceptions process to gain coverage.

6. Alternative Funding Programs (AFPs)

Alternative funding programs are arrangements that some employer plan sponsors make with third-party entities that seek to shift the cost of certain medicines away from a health plan and onto external sources, such as charitable or manufacturer assistance programs. These programs are increasingly offered by third-party vendors who can convince employers to drop coverage of some or all specialty medicines. If an employer were to do so and a patient was not eligible for an alternative funding program, the patient can be responsible for the full cost of a medicine or need to receive an exception for coverage. AFPs can cause care delays and create extra work for patients and providers.