Key points
- A drug your plan denies and a drug you cannot afford are two problems. You can work on both at once.
- If the plan will not cover a drug, ask for an exception or appeal. Your prescriber has to supply the medical reasons.
- Nonprofit directories and some condition foundations list financial help for medicines. We point to them and cannot tell you what you will qualify for.
- Each assistance program sets its own rules, including how it treats your kind of coverage. Ask before you apply.
If your plan will not cover a drug, ask for an exception or file an appeal. If you cannot afford your share of a drug, look at assistance directories and nonprofits. You can do both at the same time. This page points to places to look and does not promise what you will qualify for.
What this means
There are two different problems here.
The first is coverage: your plan will not pay for a drug, makes you try another drug first, limits the quantity or puts it on a high tier. That is a decision you can challenge with an exception request or an appeal, and your prescriber has to supply the medical reasons.
The second is cost: the plan covers the drug but your share is more than you can pay. Assistance may come from a drug maker, a charity or a nonprofit that keeps a list. This page does not list individual drug-maker programs. Ask your prescriber’s office and the pharmacy whether the drug’s maker has a program, and look up the drug on the maker’s own site.
What to do
- Get the reason for the refusal. Read the denial or the pharmacy rejection. See formulary exceptions, step therapy exceptions and drug limits and switches. The drug exception planner points you to the right request.
- Ask your prescriber to support the request (your prescriber’s step). For an exception, the plan needs the prescriber’s reasons. The formulary exception letter and the step therapy exception letter are drafts to review with your prescriber.
- Tell the pharmacy what happened. The pharmacy rejection script helps with the call.
- Search a directory for financial help. The Patient Advocate Foundation, a nonprofit, runs a National Financial Resource Directory. It is a search tool that builds a list of organizations offering financial help based on your situation. The National Organization for Rare Disorders has a patient assistance page covering help with medication, premiums and copays, testing and travel, searchable by diagnosis, with a patient services phone line.
- Check your condition’s foundation. Some condition foundations list financial assistance for people with that condition. The Crohn’s & Colitis Foundation, for example, lists patient financial assistance programs and explains copay accumulator and maximizer programs.
- Ask a case manager if you qualify. Patient Advocate Foundation case managers help eligible patients apply for coverage programs and negotiate bills. Its page says to call 1-800-532-5274, Monday to Friday, 8:30 a.m. to 5:00 p.m. Eastern. Eligibility rules apply, including a serious diagnosis and active treatment, and the page says the foundation limits the number of new cases it accepts each day. If you are turned away, call back.
- If you have Medicare, ask your counselor. A State Health Insurance Assistance Program counselor gives free, one-on-one Medicare help. Ask what help with drug costs you may qualify for. See Medicare counseling.
- Ask each program the same questions. Who qualifies and with what coverage? How much does it pay? For how long, and how do I renew? What information does it keep, and who sees it? Write down the answers.
What your plan may say, and what to say back
“This drug is not on our formulary.” I am asking for a formulary exception. My prescriber will send a supporting statement. Please tell me the deadline for a decision.
“You must try a cheaper drug first.” I am asking for a step therapy exception. My prescriber will explain why that step is not right for me.
The rule
A Medicare drug plan member can ask the plan to cover a drug that is not on its formulary, or to charge a lower cost-sharing tier. The prescriber must give an oral or written supporting statement. For an exception request, the 72-hour or 24-hour decision clock starts when the plan receives the prescriber’s statement. See Code of Federal Regulations (CFR), title 42, section 423.578 and 42 CFR 423.568.
This rule is for Medicare drug plans. Rules for other plans differ. See formulary exceptions.
Watch for
- Assistance is not an appeal. A foundation grant does not change the plan’s decision, and the appeal deadline keeps running. Check the date on your notice, which controls.
- Copay accumulator and maximizer programs. The Crohn’s & Colitis Foundation explains how these programs work and how to tell from your plan documents whether your plan has one. It reports that some states have banned accumulators. Check your state.
- Rules about coverage type. Programs differ in how they treat people with government coverage. Ask each one before you apply.
- Limited funds. Directories can be out of date and funds can close. Call to confirm.
What next
- Medicare drug plan appeals: the steps for a Medicare Part D denial.
- Where to get free help, by coverage type: people who can help with the appeal itself.
- Find free help: all the pages on this topic.