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Health plans will help pay the cost of certain prescription medications. You may be able to buy other medications, but medications on your plan’s “formulary” (approved list) usually will be less expensive for you.
To find out which prescriptions are covered through your new Marketplace plan:
Some insurance companies may provide a one-time refill for your medication after you first enroll. Ask your insurance company if they offer a one-time refill until you can discuss next steps with your doctor.
If you can’t get a one-time refill, you have the right to follow your insurance company’s drug exceptions process, which allows you to get a prescribed drug that’s not normally covered by your health plan. Because the details of every plan’s exceptions process are different, you should contact your insurance company for more information.
Generally, to get your drug covered through the exceptions process, your doctor must confirm to your health plan (orally or in writing) that the drug is appropriate for your medical condition based on one or more of the following:
If you get the exception:
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.
Just like different health plans cover different medications, different health plans allow you to get your medications from different pharmacies (called “in-network pharmacies”). Call your insurance company or visit their website to find out whether your regular pharmacy is in-network under your new plan and, if not, what pharmacies in your area are in-network. You can also learn if you can get your prescription delivered in the mail.
If you have additional questions, call 1-800-318-2596. (TTY: 1-855-889-4325)