Can you ask your insurance to make an exception with a medication?
Asked by: Mr. Keanu Hahn Jr. | Last update: June 3, 2025Score: 5/5 (19 votes)
What is an exception request for medication?
Exceptions requests are granted when a plan sponsor determines that a requested drug is medically necessary for an enrollee. Therefore, an enrollee's prescriber must submit a supporting statement to the plan sponsor supporting the request.
Can your insurance force you to use a specific pharmacy?
Your insurance company may require you to get your medicine from a specific specialty pharmacy that it chooses. This may mean you can't use your healthcare provider's pharmacy or a local pharmacy that you have trusted for many years.
Can an insurance company refuse to cover a medication?
When your doctor orders a medication that is not listed in the formulary, the insurance company may overrule your doctor's orders. This can be frustrating for both your doctor and you. Always remember that you have the right to appeal your insurer's decision.
How to hide medication from insurance?
Drugs can be secret, too
Under HIPAA, you have the right to ask your pharmacist not to tell your health insurance company about any drugs you take. Again, pay in full so the provider or pharmacy does not need to get paid by your insurance company.
What to do when your medication is not listed in your insurance formulary
Can you petition your insurance to cover a medication?
Insured patients who are facing uncovered medication needs may have an option to ask their insurance company to cover it through a formulary exception request.
How to get a tier exception approved?
The doctor will need to send paperwork, or online forms, indicating the reason that you cannot take the preferred medications and must be approved for one that is not currently on the formulary. The documentation should describe how preferred medication(s) on lower tiers are better for you.
Can insurance companies dictate your medication?
As you likely know, prior authorization allows insurers to review doctors' orders and decide whether they will cover prescribed services. Such policies were initially established to help reduce healthcare costs by controlling patient access to more expensive or investigative medications, treatments, and therapies.
Why did my insurance not cover my medication?
This is one of the most common reasons coverage is denied for a prescription. Certain medications require prior authorization – or approval – from your health insurance company. This means your insurer will deny coverage until your healthcare provider fills out certain forms indicating why you need that medication.
Can I use GoodRx instead of my insurance?
Can I use GoodRx instead of insurance? You can and should use a GoodRx discount instead of your health insurance or Medicare if the price is lower. Keep in mind that you cannot use GoodRx and insurance at the same time.
Can you sue insurance company for denying medication?
There are laws designed to protect consumers in the state of California and across the nation. It's not uncommon for policyholders to sue their healthcare insurers for denial of a claim, mainly when the claim is for a service that is crucial to their health and future or the health and future of a loved one.
Can a doctor force you to use a specific pharmacy?
In the US, the physician cannot dictate your use of pharmacy. I would commonly make a recommendation to patients based on my knowledge of the cost of the medication.
Can I choose not to use insurance for prescriptions?
You may choose not to use insurance if the service you need isn't covered, or it's less expensive if you pay out of pocket.
What is an exempted prescription?
Background: Exempted Prescription Products. Over time, DEA has exempted prescription drug products from certain parts of the CSA when the products meet the requirements for exemption, including the requirement to contain active ingredients believed to vitiate the potential for abuse.
What is a policy exception request?
Policy exceptions
If another business or vendor fails to fulfill your organization's policies, it should submit a policy exception request form. In turn, your chief information security officer (CISO) can approve or deny the policy exception request based on the risk it poses to your organization.
How to write a tier exception letter?
I am writing to request a tiering exception for my patient, [patient's name], who is currently a member of [name of health plan]. * The prescription is for [product, dosage and frequency], which is medically appropriate and necessary for this patient who has been diagnosed with [condition], [ICD code(s)].
What if my insurance won't approve my prescription?
My insurer denied my request for an exception. Now what do I do? If your health insurance company won'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 appeals process.
Who decides what medications are covered by insurance?
The price patients eventually pay gets determined later, when an insurance company or pharmacy benefits manager decides where a drug fits on a list of covered treatments called a formulary.
What is the 28 day prescription rule for controlled substances?
It refers to the number of days you may need to wait between refills of 30-day prescriptions that are considered controlled substances. If you have a medication that follows the 28-day rule on a 30-day supply, it means you can get a refill no earlier than 2 days before the 30 days are up.
Why is my insurance not paying for my medication?
Just because a medication is “covered” doesn't mean that your insurance is actually paying for the medication. It's possible that you have a deductible for your plan that has not yet been met. If so, your plan will expect you to pay the full deductible before it contributes towards healthcare costs.
What is a pharmacy override?
A prescription override is a request to have a prescription filled for more than a 30 day supply. Who is eligible for the override? Overrides can be requested by a student traveling outside of the United States for more than a 30 day period.
How to write an exception letter?
When writing your request be sure to include the required information: Paragraph 1: What are you requesting? Paragraph 1: Why you are requesting the exception. Paragraph 2: Provide details on the circumstances that should be considered. Paragraph 3: What is your desired outcome?
What is a formulary exception for medication?
Under a closed formulary pharmacy benefit, the health plan or payer provides coverage only for those drugs listed on the formulary. An exception procedure can be used by prescribers and patients to request coverage for drugs that are not included on a plan's drug formulary.
Who determines the tier level of a drug?
Each plan decides which drugs on its formulary go into which tiers. In general, the lowest-tier drugs are the lowest cost. Plans negotiate pricing with drug companies. If a plan negotiates a lower price on a particular drug, then it can place it in a lower tier and pass the savings on to its members.