Just as many healthcare plans provide options for different medications, health plans also allow for you to get your medicines from pharmacies known as “in network” pharmacies. You’ll want to contact your insurance company or take a look at their website to determine if the pharmacy you work with takes your new plan. If you find out that it’s not covered with the pharmacy you already work with, you may be able to see on the internet what other pharmacies do cover the plan that you have.
As an alternative, you may be able to receive your medications through the mail. Doing your research and finding out what you are eligible for is likely to ease a lot of your fears. If your health insurance company won’t cover your prescription, you may also pursue your right to appeal that decision and have the case reviewed by a neutral third party.
To learn details about what prescriptions are covered and what pharmacies are considered in-network, visit the insurer’s website to determine the list of prescriptions that are included with your plan, verify your coverage and benefits summary, contact the insurer directly, or review the hard copy materials you received.
If you get to your pharmacy and are told that your plan no longer covers it, some insurers may be willing to allow you a one-time refill after you initially enroll in the plan. This is to give you some time to determine the next best step by meeting with your doctor. You can also initiate the insurer’s drug exception process, but you need to discuss this directly with a plan representative as their rules can vary.
For the most part, your doctor will have to confirm to your health plan representatives that the drug is appropriate for your medical condition based on a few factors, such as there being a limit on the number of doses you’re allowed, whether an alternative drug that is covered by your plan is likely to give you side effects that could be harmful or dangerous to you, or whether other drugs that are covered by your health insurance plan are not as likely to be as effective as the drug which you are presently taking.
As you can see, there are multiple options to take if your medication or pharmacy is no longer included in your plan.