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Common coverage questions

Once you’re enrolled in a health plan and your coverage has started, you can use it to help cover medical costs for services like:

If you haven’t had private health insurance before or if it’s been a while, you may want to learn about using your coverage and improving your health using our Roadmap to Better Care and a Healthier You.

If your health insurance company doesn’t pay for a specific health care provider or service, you can appeal an insurance company decision.

Unsure about your coverage? Learn what to do if you’re not sure you’re enrolled, or haven’t received your insurance card.

Learn more if your new coverage is through your state’s Medicaid or CHIP program.

Getting prescription medications

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.

Does my new insurance plan cover my prescription?

To find out which prescriptions are covered through your new Marketplace plan:

  • Visit your insurer’s website to review a list of prescriptions your plan covers
  • See your Summary of Benefits and Coverage, which you can get directly from your insurance company, or by using a link that appears in the detailed description of your plan in your Marketplace account.
  • Call your insurer directly to find out what is covered. Have your plan information available. The number is available on your insurance card the insurer's website, or the detailed plan description in your Marketplace account.
  • Review any coverage materials that your plan mailed to you.

What do I do if I’m at the pharmacy to pick up my prescription, and they said my plan no longer covers it?

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:

  • All other drugs covered by the plan haven’t been or won’t be as effective as the drug you’re asking for
  • Any alternative drug covered by your plan has caused or is likely to cause side effects that may be harmful to you
  • If there’s a limit on the number of doses you’re allowed:
    • That the allowed dosage hasn’t worked for your condition, or
    • The the drug likely won’t work for you based on your physical or mental makeup. For example, based on your body weight, you may need to take more doses than what’s allowed by your plan.

If you get the exception:

  • Your health plan generally will treat the drug as covered and charge you the copayment that applies to the most expensive drugs already covered on the plan (for example, a non-preferred brand drug).
  • Any amount you pay for the drug generally will count toward your deductible and/or maximum out-of-pocket limits.

Can I get the non-covered drug during the exceptions process?

  • While you’re in the exceptions process, your plan may give you access to the requested drug until a decision is made.

My insurer denied my request for an exception. Now what do I do?

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.

Can I go to my regular pharmacy to get my medication?

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)

Getting regular medical care

Most health plans give you the best deal on services when you see a doctor who has a contract with your health plan. While you may be able to see doctors who don’t contract with your plan, visiting an “in-network” provider usually means you’ll have lower out-of-pocket costs.

Finding a doctor in your plan

To find out if your doctors and other health care providers are covered by your new Marketplace plan, or to find a covered provider if you don’t have one yet:

  1. Visit your health plan’s website and check their provider directory, which is a list of the doctors, hospitals, and other health care providers that your plan contracts with to provide care.
  2. See your health plan’s provider directory. You can get this by contacting your plan, visiting the plan’s website, or using a link that you’ll find on the plan description in your Marketplace account. 3. Call your insurer to ask about specific providers. This number is on your insurance card and the insurer’s website.
  3. Call your doctor’s office. They can tell you if they accept your health plan.
  4. Call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325). A trained representative can help you find your insurer’s number

Is there an appeals process if I go to my regular doctor and find out later that my new plan doesn’t cover them?

Yes. If your health insurance company doesn’t pay for a visit to the doctor, you have the right to appeal the decision and have it reviewed by an independent third party. Learn about the appeals process.

Getting emergency care

In an emergency, you should get care from the closest hospital that can help you. That hospital will treat you regardless of whether you have insurance. Your insurance company can't charge you more for getting emergency room services at an out-of-network hospital.

I’m having an emergency. Should I go straight to the hospital or do I need to call my insurer first?

In a true emergency, go straight to the hospital. Insurers can’t require you to get prior approval before getting emergency room services from a provider or hospital outside your plan’s network.

What does it mean that insurance companies can’t charge me more?

Insurance plans can’t make you pay more in copayments or coinsurance if you get emergency care from an out-of-network hospital. They also can’t require you to get prior approval before getting emergency room services from a provider or hospital outside your plan’s network.

Will I have to pay anything?

This depends on the plan that you chose and the hospital you go to. This care may be subject to a deductible, for example, or a hospital may have particular rules in place.

Using coverage and improving your health

Now that you have health coverage, learn what you can do to stay healthy and get the care you need.

Read the Roadmap to Better Care and a Healthier You for tips and information on:

  • Putting your health first
  • Understanding your coverage
  • Finding a provider
  • Making an appointment
  • Preparing for your first visit
  • Deciding if you like your provider
  • Taking your next steps to good health

Appealing an insurance company decision

If your health insurance company doesn’t pay for a specific health care provider or service, you have the right to appeal the decision and have it reviewed by an independent third party.

Your insurance company must first notify you in writing within a set amount of time (based on the type of claim you filed) to explain why they denied coverage. They also must let you know how you can appeal their decisions.

If the timeline for the standard appeals process would seriously put your life at risk, or risk your ability to fully function, you also can file an appeal that would get you a quicker (or “expedited”) decision. If you meet the standards for an expedited external review, the final decision about your appeal must come as quickly as your medical condition requires, and no later than 72 hours after your request for external review is received.

If you have questions, contact the Marketplace Call Center at 1-800-318-2596. (TTY: 1-855-889-4325.)

Learn more about the appeals process.