Your Prescription Wasn’t Covered. Here’s What You and Your Doctor Can Do

You need a new drug and find your prescription isn’t covered. Or you’ve taken a drug in the past and find it’s no longer covered. Find out why meds may not be covered, and what you can do next.

Health plans cover a wide range of medications. But they don’t cover them all. Often, other drugs on the drug list, branded or generic, are used to treat the same condition and may be a lower cost.

If you’ve been told a prescription medicine isn’t covered, the first step is to find out more. Learn why the medicine is not covered. Ask the pharmacist. Check to see that it’s not a paperwork issue, like not getting pre-approval, also called prior authorization. If your drug needs to be given to you by a health care provider and in a hospital, office or health care setting, it may be covered under your medical benefit instead.

What you do next depends on why the prescription may not have paid under your pharmacy benefit.

In all cases:

• Treatment decisions are between you and your doctor. Ask your doctor about your therapeutic options. There may be a lower-cost alternative available.
• You can pay for the medication out-of-pocket, at a higher cost or up to the full retail price. Talk to the pharmacist and see if there are any ways to save money.
• Your doctor can ask for a coverage exception (if benefits allow) or a clinical review from your health plan.
• If the request was denied, you or your doctor can appeal the decision.

Lists of covered drugs, also called formularies, change. These lists are routinely reviewed so covered drugs can change from time to time. If your prescription isn't covered because it isn't on the drug list:

• Your doctor can choose a different medication that is on the Drug List.
• Your doctor can ask for a coverage exception (if benefits allow) from your health plan with the documentation required.

Your prescription isn't covered because it's on the Prior Authorization or Step Therapy programs list:

• You may need to take extra steps before getting your prescription filled. These clinical review programs help make sure select drugs are being used safely, as intended and at the best cost.
• If your drug needs a prior authorization, your doctor will need to send documentation before the drug may be covered by your health plan.
• You may need to try a less costly, or more common drug before you “step up” to your prescribed drug. If you cannot try the common drug, your doctor will need to send documentation why it will not work for you.

Your prescription isn't covered because it's FDA-approved for a health problem you don't have:

• Your doctor chooses a different medication that’s approved for the condition being treated.
• Your doctor provides the required documentation on why off-label use may be needed.

When in Doubt, Find Out

Remember, you or your doctor can check in advance to find out if a drug is covered and if there are any special rules. .

You can check your prescription benefit information. Log in to your Blue Access for Members^SM (BAM)^SM account. Select the Coverage and Benefits tab, and click on Pharmacy, then Manage Prescriptions and Benefits. Or to check your drug list, see Prescription Drug Lists at bcbstx.com. Select Prescription Drug Lists, then choose your plan type.

Or, you or your doctor can check with us at the phone number listed on your member ID card.