How to Get Insurance to Pay for Brand-Name Drugs

Getting insurance to pay for brand-name drugs can be a challenge, but it's not impossible. If your insurance plan covers brand-name drugs, you can use the formulary to find out which medications are covered.

Your insurance plan may have a formulary or a list of covered medications. This list can be found on your insurance provider's website or by contacting their customer service.

Insurance companies often have their own lists of approved medications, known as formularies, which can affect the coverage of brand-name drugs.

If your prescribed medication isn't on the formulary, you may have to pay full price or switch to a similar generic or brand-name medication that is covered.

Formularies can vary greatly between plans, so it's essential to review your plan's list of covered medications to understand what's included.

Some plans may cover weight loss drugs only after you've tried a cheaper alternative.

Medicare offers stand-alone prescription drug coverage through a Part D drug coverage plan, which can be added to certain plans, including original Medicare and Medicare Advantage Plans.

To get stand-alone prescription drug coverage with Medicare, you'll need to have Medicare Part A or Part B.

You can ask for the brand drug, and it's a good idea to do so if you're concerned about the quality or effectiveness of a generic version. Have your prescribing physician write "do not substitute" or "dispense as written" or "brand medically necessary" on the prescription.

It's also helpful to understand your health insurer's coverage of the brand vs. generic medication. You can check your policy documents or contact your insurer's customer service to find out what's covered.

If you're able to get a brand name prescription, it's because your insurer has decided to cover it. This can be a good option if you're taking a medication that's critical to your health.

Manufacturer assistance can be a game-changer when trying to get insurance to cover brand-name drugs.

Some manufacturers offer patient assistance programs that can significantly reduce the cost of medication, making it more affordable for those who need it.

For example, AbbVie, the manufacturer of Humira, has a patient assistance program that can provide patients with a free or reduced-cost prescription for up to one year.

Insurance companies may not always cover the full cost of brand-name medications, even if they're prescribed by a doctor.

This is because insurance companies often negotiate lower prices with generic manufacturers, making the brand-name version less cost-effective.

In some cases, insurance companies may not cover brand-name medications at all, especially if there's a generic alternative available.

Insurance companies can override your doctor's prescription if the drug is not in the formulary, which is the list of medications covered by your insurance plan. Each plan has its own formulary, and it can change throughout the year.

Plans can vary in how restrictive they are, with some covering weight loss drugs when prescribed and others only after trying a cheaper option. If your prescription is not in the formulary, you'll either pay full price or switch to a similar, covered drug.

PBMs, or pharmacy benefit managers, play a significant role in defining medication costs and access to medications. They're middlemen between drug companies and pharmacies, and three PBMs control 80% of medication benefits for 260 million people in the US.

A formulary is a list of prescription drugs covered by your health insurance plan. It's also known as the prescription drug list.

The formulary will have each medication that's covered, along with any details like refill limits. If your prescription isn't on the formulary, you'll either pay full price or switch to a similar drug that's covered.

Plans are required to cover a wide range of medications, but they can vary based on the specific medications or brand names they'll cover. Some plans might cover weight loss drugs when prescribed, while others might only cover them after you've tried a cheaper alternative.

The three largest PBMs (Pharmacy Benefit Managers) control 80% of medication benefits for 260 million people in the US. They're powerful middlemen between drug companies and pharmacies, and they help define medication costs and formularies for health insurers.

Here's a breakdown of the factors that influence your prescription costs:

To find out the cost of a prescription, you'll usually need to look up the medication in the plan's drug formulary and then check the plan's benefit document to find out your copay or coinsurance for that drug tier.

Insurance coverage for prescriptions can be complex, but understanding the basics can help you navigate the process. Your insurance plan will determine which drugs are covered and what you'll pay out of pocket.

The coverage tier your medications are in plays a big role in how much you'll pay for prescriptions. If your medication is in a lower tier, you'll likely pay less.

Coverage restrictions like prior authorization can make it harder to get your insurance to cover certain prescriptions. This means you'll need to get your insurance company's approval before they'll cover your prescription.

Prior authorization involves the insurance company checking that the drug is being used for an approved medical condition and that the dosage makes sense. This process can take some time, so be patient.

Some insurance plans will only cover your prescription if you first try a cheaper drug, a process known as step therapy. This means you may need to try a different medication before your insurance will cover the one your doctor prescribed.

To get the best coverage, you'll usually need to use one of your plan's preferred pharmacies. Each plan will have a list of preferred pharmacies where you'll pay the lowest rates for your prescriptions.

Here are some common insurance plan restrictions:

If you're struggling to get your insurance to cover a prescription, you may be able to request a coverage exemption or appeal an insurance denial. This can be a good option if you need a prescription that's not covered by your plan or that's in a high coverage tier.

Insurance plans may add coverage requirements for covered drugs, which can make it harder to get your insurance plan to help pay for medications. Prior authorization for medication is when you have to get your insurance company's approval before it will cover your prescription. This involves the insurance company checking that the drug is being used for approved medical conditions and that the dosage makes sense.

Insurance plans may also use step therapy, where they'll only cover your prescription if you first try a cheaper drug. For example, you might need to try a cheaper diabetes medication for three months before your insurance company will cover the more expensive Ozempic.

To get the best coverage, you'll usually need to use one of your plan's preferred pharmacies. These are listed in your plan's documents, and using them will help you pay the lowest rates for your prescriptions.

Prescription plan restrictions can be a real challenge for those of us who need to manage our medications. Some insurance plans may add coverage requirements, making it harder to get your plan to help pay for medications.

Prior authorization for medication is a common restriction, where you need to get your insurance company's approval before they'll cover your prescription. This can be a hassle, but it's worth it to get the medication you need.

Step therapy is another restriction that can be frustrating. This is when an insurance plan will only cover your prescription if you first try a cheaper drug. For example, if your doctor prescribes Ozempic for diabetes, UnitedHealthcare may only cover it if you first try a cheaper diabetes medication for three months.

You'll usually need to use one of your plan's preferred pharmacies to get the best coverage. Each plan will have a list of preferred pharmacies where you'll pay the lowest rates for your prescriptions.

Here are some common prescription plan restrictions to be aware of:

These restrictions can be a challenge, but there are steps you can take to get the coverage you need.

Insurance companies categorize prescription medications into different tiers, which affects how much you pay for each medication.

The tier your medication falls under will determine the cost split with your insurance.

Tier 1 and 2 drugs, which are generic or common brand name drugs, are usually the cheapest.

Tier 3 and 4 drugs, which are often expensive or specialty medications, will cost you more.

To find out how much you'll pay for a prescription, first look up the medication in your plan's drug formulary to see what tier it's in.

Then, check the plan's benefit document to see your copay or coinsurance for that drug tier.

Here's a rough breakdown of what you might expect to pay for each tier: