For your convenience, we accept all major health plans as well as many local, statewide and national prescription plans including Medicaid and Medicare Part D. We understand the many nuances of prescription drug insurance plans and are available and willing to help answer any questions or concerns you have. Feel free to call us or stop by to discuss your options and our insurance plan participation.
What to Know About Getting Your 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” (drug list) usually will be less expensive for you.
Does my new insurance plan cover my drugs?
Find out which drugs your Insurance plan covers:
- Visit your insurer’s website to review a list of drugs your plan covers.
- See your “Summary of Benefits and Coverage,” which is also available in “See Plans Before I Apply” on HealthCare.gov.
- Call your insurer directly to find out what’s covered, and have your plan information available. The number is on your insurance card and the insurer’s website.
- Review any coverage materials that your plan sent to you.
I’m at the pharmacy to pick up my prescription, and they said my plan no longer covers it. What do I do?
Some insurers may give a one-time refill for your prescription drug after you first enroll. Ask your insurer if they offer a one-time refill until you can discuss next steps with your doctor.
If you can’t get a one-time refill, you have the right to follow your insurer’s drug exceptions process, which lets you get a prescribed drug that’s not normally covered by your health plan. Because the details of every plan’s exceptions process are different, you should contact your insurer for more information.
Generally, to get your drug 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 based on one or more of these conditions:
- All other drugs covered by the plan haven’t been or won’t be as effective as the drug you’re requesting.
- Any alternative drug covered by your plan has caused or is likely to cause side effects that may be harmful to you.
- If there’s a limit on the number of doses you’re allowed:
- That allowed dosage hasn’t worked for your condition, or
- The drug likely won’t work for you based on your physical or mental makeup. For example, based on your body weight, you may need to take more doses than what’s allowed by your plan.
If you get the exception:
- Your health plan generally will treat the drug as covered and charge you the copayment that applies to the most expensive drugs already covered on the plan.
- Any amount you pay for the drug generally will count toward your deductible and/or maximum out-of-pocket limits.
Can I get the non-covered drug during the exceptions process?
While you’re in the exceptions process, your plan must give you access to the drug you and your doctor asked for until a decision is made.
My insurer denied my request for an exception. Now what do I do?
If your health insurance company won’t pay for your drug, you have the right to appeal the decision and have it reviewed by an independent third party. To learn more about the appeals process, read “Appeals: eligibility and health plan decisions in the Health Insurance Marketplace.”