get prescription drugs
Health plans will help pay the cost of certain prescription drugs. You may be able to buy other drugs, but drugs on your plan’s “formulary” (approved list) will generally be less expensive for you.
Does my new insurance plan cover my prescription?
To find out which prescriptions are covered through your new Marketplace plan:
- visit your insurer’s website to review a list of prescriptions covered by your plan
- view your summary of benefits and coverage, which you can get directly from your insurance company, or through a link in your detailed plan description in your marketplace account.
- call your insurer directly to find out what is covered. Have your plan information available. the number is available on your insurance card, on the insurer’s website, or in the detailed plan description in your marketplace account.
- Review the coverage materials that your plan mailed to you.
- all other drugs covered by the plan have not been or will not be as effective as the drug you are requesting
- any alternative drugs covered by your plan have caused or are likely to cause side effects that may be harmful to you
- if there is a limit on the number of allowed doses:
- that the allowed dose has not worked for your condition, or
- The drug may not work for you depending on your physical or mental make-up. for example, depending on your body weight, you may need to take more doses than your plan allows.
- Your health plan will generally treat the drug as covered and charge you the copay that applies to more expensive drugs already covered by the plan (for example, a non-preferred brand-name drug).
- Any amount you pay for the drug will generally count toward your deductible and/or maximum out-of-pocket limits.
- While you are in the exception process, your plan may give you access to the requested drug until a decision is made.
if you get the exception:
Can I get the non-covered drug during the exception process?
my insurer denied my exception request. now what do i do?
If your health insurance company doesn’t pay for your prescription, you have the right to appeal the decision and have it reviewed by an independent third party. Learn more about the appeal process.
can I go to my regular pharmacy to get my medicine?
Just as different health plans cover different drugs, different health plans allow you to get your drugs from different pharmacies (called “in-network pharmacies”). Call your insurance company or visit their website to find out if your regular pharmacy is in your new plan’s network and, if not, which pharmacies in your area are in network. You can also find out if you can get your prescription in the mail.
If you have additional questions, please call 1-800-318-2596. (tty: 1-855-889-4325)
What do I do if I’m at the pharmacy to pick up my prescription and they tell me my plan no longer covers it?
Some insurance companies may provide a one-time refill of your medication after you first enroll. ask your insurance company if they offer a one-time refill until you can discuss next steps with your doctor.
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If you are unable to obtain a one-time refill, you have the right to follow your insurance company’s drug exception process, which allows you to fill a prescription not normally covered by your health plan. Because the details of each plan’s exception process are different, you should contact your insurance company for more information.
Generally, for your drug to be covered through the exceptions process, your doctor must confirm to your health plan (orally or in writing) that the drug is appropriate for your medical condition under one or more of the following criteria: following: