What to Do If Your Insurance Won’t Cover a Prescription

Finding out that your insurance denied a prescription can be frustrating and confusing. But denials don’t always mean you’re out of options—there are ways to challenge the decision, find covered alternatives, and even get financial assistance.

This guide walks you through why prescriptions get denied–and what you can do next.

Why Was My Prescription Denied?

Insurance companies deny prescriptions for several reasons. Understanding the specific reason can help you take the right next steps.

• The Drug Isn’t on Your Plan’s Formulary: Every insurance plan has a list of covered drugs, known as a formulary. If your medication isn’t on this list, the insurer may deny coverage.
• Step Therapy Requirements: Some insurers require you to try a lower-cost or generic alternative before approving a more expensive medication.
• Quantity Limits: Your insurance may only cover a specific amount of medication within a set timeframe.
• Prior Authorization Required: Some medications need special approval from your doctor before the insurer will cover them.
• Medical Necessity Denial: The insurer may claim the medication isn’t necessary based on their internal guidelines.

If your prescription is denied, don’t assume that’s the final word. There are ways to challenge the decision and secure coverage.

Let a Solace advocate help you fight insurance denials.

How to Find Out Why Your Prescription Wasn’t Covered

The best way to determine the reason for a denial is by reviewing your Explanation of Benefits (EOB) or denial letter.

• Check the Code: The letter should include a denial code explaining why the claim was rejected.
• Call Your Insurance Provider: If the denial reason is unclear, contact your insurer’s customer service for clarification.
• Review Your Plan’s Drug Coverage Rules: Some medications require extra steps for approval, such as prior authorization or proof of medical necessity.

Tip: Keep a written record of any calls with your insurance provider, including the representative’s name, date, and details of the conversation.

Want someone to handle this for you? A Solace advocate can help.

Can My Doctor Help Me Get a Covered Alternative?

If your insurance won’t cover a medication, your doctor may be able to suggest a different option.

• Ask About Covered Alternatives: Your doctor may be familiar with medications that are similar but included in your plan’s formulary.
• Request Medical Documentation: If your doctor believes the original medication is essential, they can submit a letter explaining why alternatives won’t work for you.

Doctors are often familiar with the insurance process, but their time is limited. A Solace advocate can coordinate with your doctor and insurer to get you covered faster.

Get an advocate to manage this for you.

How to Request an Exception or Special Approval

If your medication isn’t covered, you may be able to request an exception.

• Formulary Exception Request: This asks your insurance company to cover a drug that isn’t normally included in your plan. Your doctor must explain why it’s medically necessary.
• Prior Authorization Request: If your insurer requires prior authorization, your doctor must submit paperwork proving you need the medication.

Every insurance company has its own rules, so following the correct process is critical.

Let a Solace advocate handle the paperwork for you.

What to Do If Your Insurance Still Won’t Cover Your Prescription

If your request is denied, you have the right to appeal the decision.

• File a Formal Appeal: Submit an appeal letter with supporting documentation from your doctor explaining why the medication is necessary.
• Follow Timelines Carefully: Insurers have strict deadlines for appeals—missing them could mean starting over.
• Consider an External Review: If your appeal is denied, some insurers allow you to escalate the decision to an independent reviewer.

Appealing an insurance denial can be time-consuming and complex.

Need help filing an appeal? Solace can take care of it for you.

Financial Assistance Options for Medications

If your insurance won’t cover your prescription—or the copay is too high—there are ways to reduce costs.

• Prescription Assistance Programs (PAPs): Many pharmaceutical companies offer assistance programs for patients who can’t afford their medications. Check NeedyMeds for eligibility.
• Discount Programs: Services like GoodRx and SingleCare offer discounts that may be cheaper than your insurance copay.
• Nonprofit Organizations: Groups like the Patient Advocate Foundation and RxAssist help connect patients with financial assistance programs.

These programs can significantly reduce out-of-pocket costs, especially for expensive medications.

A Solace advocate can help you find the best financial assistance options.

How Medicare Can Help with Prescription Coverage

If your medication isn’t covered, Medicare may help, depending on your plan. Understanding your coverage options can prevent unnecessary out-of-pocket costs.

• Medicare Part D (Prescription Drug Plans): Covers many prescription medications but has a formulary, which means some drugs may not be included. You can request a formulary exception if your medication isn’t covered.
• Medicare Advantage (Part C) Plans: Some Medicare Advantage plans offer prescription drug coverage, but coverage rules vary by plan.
• Extra Help Program: If you have limited income, you may qualify for Medicare’s Extra Help program, which reduces prescription drug costs.

If your Medicare plan denies a prescription, you have the right to appeal the decision or seek alternative coverage options.

Need help navigating Medicare benefits? A Solace advocate can guide you.

Don’t Navigate Insurance Denials Alone

Prescription denials can be stressful, but you have options. From requesting an exception to finding lower-cost alternatives, there are steps you can take to get the medication you need.

A Solace advocate can handle the entire process—from filing paperwork to negotiating with your insurer—so you don’t have to deal with it alone.

Talk to a Solace advocate today.

FAQ: Common Questions About Prescription Coverage

Why would my insurance deny my prescription?

Insurance companies may deny prescriptions due to step therapy requirements, formulary exclusions, or a lack of prior authorization. Understanding the specific reason for denial is crucial. Review your Explanation of Benefits (EOB) or denial letter to identify the exact cause and take appropriate action to challenge the decision.

What’s a formulary exception, and how do I request one?

A formulary exception is a formal request to your insurance provider to cover a prescription drug that is not included in the formulary (list of covered medications). To initiate this process, your healthcare provider must submit detailed medical documentation explaining the necessity of the non-formulary drug over alternatives. This documentation should emphasize the medical need and potential adverse effects of not using the prescribed medication.

Can I get financial help if my prescription isn’t covered?

Yes, there are several avenues for financial assistance if your prescription is denied coverage. Pharmaceutical companies often offer patient assistance programs that provide medications at reduced costs. Additionally, nonprofit organizations and prescription discount services like GoodRx and SingleCare can help lower out-of-pocket expenses. Exploring these options can significantly reduce the financial burden of non-covered prescriptions.

Is there someone who can help me with my prescription denial?

Absolutely! If you're struggling with a prescription denial, consider seeking the expertise of a Solace advocate. Advocates are experienced in navigating insurance challenges, handling denials, securing prior authorizations, and managing appeals. They provide valuable support, so you don’t have to face the complexities of insurance coverage alone.

This article is for informational purposes only and should not be substituted for professional advice. Information is subject to change. Consult your healthcare provider or a qualified professional for guidance on medical issues, financial concerns, or healthcare benefits.