Finding out at the pharmacy that your prescription is not covered can be frustrating, but it does not always mean that you have to pay the full cost yourself.
First, find out why the prescription was not covered.
- Possible reasons include:
- The medication is not on your plan’s formulary.
- Prior authorization is required.
- The plan requires step therapy.
- There is a quantity limit.
- The prescription was processed incorrectly.
- A covered alternative medication is available.
Ask the pharmacist for the specific reason the claim was rejected. You can then contact your prescription drug plan or Medicare Advantage plan for additional information.
Your prescribing provider may also be able to help. Depending on the situation, the provider may prescribe a covered alternative or request a coverage determination or exception from the plan.
Do not simply abandon an important medication because the pharmacy says it is not covered. Talk with your physician or pharmacist about appropriate next steps. Never stop or change a prescribed medication without discussing it with an appropriate healthcare professional.
If you are having difficulty understanding your prescription coverage or figuring out whom to contact, contact Regional Financial Security Agency. We can help you understand your plan’s coverage rules and identify the next steps available to you.