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Prescription drug denied or not covered: exceptions and appeals

A pharmacy "not covered" message is often not the last word. Plans have a drug exception process, and a denial of that request can be appealed.

Marketplace and similar plans: the drug exception process

HealthCare.gov says you have the right to use your insurer's drug exceptions process to get a prescribed drug the plan does not normally cover. Details differ by plan, so ask the insurer how to start. Generally your doctor has to confirm, by phone or in writing, that the drug is appropriate for your condition because one or more of these is true:

• The other drugs on the plan's list have not worked, or will not work as well as the drug requested.
• An alternative the plan covers has caused, or is likely to cause, harmful side effects.
• If there is a dose limit: the allowed dose has not worked, or is not likely to work for you (for example, because of body weight).

If the exception is granted, HealthCare.gov says the plan generally treats the drug as covered, charges the copayment that applies to the most expensive covered drugs (for example a non-preferred brand), and counts what you pay toward your deductible and out-of-pocket limit. While the request is pending, the page says the plan may give you access to the drug until a decision is made. Ask. Some plans also allow a one-time refill after you first enroll.

Medicare Part D: exception types and decision times

CMS describes two kinds of Part D exception: a tiering exception (a non-preferred drug at the lower price of a preferred tier) and a formulary exception (a drug not on the plan's list, or a waiver of a rule such as step therapy, prior authorization or a quantity limit). The prescriber must send a supporting statement, verbally or in writing; if verbal, the plan may ask for written follow-up. After it gets the statement, CMS says the plan must give notice of its decision within 24 hours for an expedited request or 72 hours for a standard one. For a request to be paid back for a drug you already bought, the limit is 14 calendar days. A denial includes the instructions for the next level, a request for redetermination. See Medicare and Medicaid appeal basics.

If the exception is denied

1. Read the reason. See how to read a denial letter.
2. File an internal appeal in writing. HealthCare.gov says to appeal within 180 days of the denial notice, and that the insurer must finish within 30 days for care not yet received or 60 days for care already received. Use the prescription drug appeal letter and attach your doctor's statement.
3. Ask for faster handling if urgent. If delay could seriously harm your health, ask for an expedited appeal; HealthCare.gov says you can ask for external review at the same time in urgent situations.
4. Request independent external review if the plan still says no: HealthCare.gov says to file within 4 months, with a decision within 45 days (72 hours, or less, if expedited). See external review.

Employer plans follow Department of Labor claim rules instead; see ERISA vs state-regulated plans. Not medical advice; never stop or change a medicine without talking to your prescriber.

Related guides

• Prior authorization denied: what to do
• How to file a health insurance internal appeal
• Independent external review: how it works
• Medicare and Medicaid appeal basics
• State insurance department directory