How Do I Know if My Medications and Drugs Are Covered by Insurance?

Prescription drug coverage varies by health plan. Even if you have insurance, your plan may not cover every medication your doctor prescribes, and covered drugs can have different costs.

What Are Drug Formularies, and Are They Covered?

It’s a good idea to check your formulary periodically, as insurers may change the list throughout the year.

How Do I Know Which Drugs Will Be Covered and Which Ones Won’t Be?

Typically, if a drug is not on the formulary, it will not be covered, even if a doctor prescribes it. “In that case, your doctor would look for a similar drug that might be available to substitute for it,” says Michael Giusti, an analyst with InsuranceQuotes.com.

How Do I Get Medications Approved by Insurance?

What can be confusing, Giusti says, is that even when a drug is on the formulary, that doesn’t automatically mean it will be covered. “In some cases, drugs that are on the formulary still require another step, called a prior authorization,” says Giusti. “That’s where the prescribing physician needs to file extra paperwork justifying why that drug is the appropriate one to use. This is often the case when it is a more expensive drug than a similar, less expensive one that is also offered.”

There are also other factors to keep in mind: “Look out for QLs [quantity limits],” says Claudia Cometa, PharmD, owner of Avanti Health Consultants and author of Patient, Empower Thyself! If there is a QL, the insurance company will only cover a specific quantity for a specified amount of time. So when you reach the limit, you will need additional approval to continue taking that medication.

How Do Biosimilars Work, and Are They Covered?

Biologics are medications derived from living organisms like bacteria or animal cells. A biosimilar is highly similar to a biologic drug that’s already approved by the U.S. Food and Drug Administration, with no clinically meaningful differences in their safety or effectiveness. Some formularies use biosimilars as lower-cost alternatives to biologics.

Cometa adds, “If the biosimilar requires a pharmacist to compound the medication, it will likely not be covered.”

What Should I Do if My Doctor Says I Need a Drug That’s Not Covered?

An effective letter adheres to a few key points. “The most important thing is language,” says Kiara DeWitt, RN, a former pediatric neurology nurse in Colleyville, Texas, whose patient advocacy efforts include helping patients decode insurance denials and navigate billing misfires. “Insurance companies respond to very specific phrasing.”