Enrolled in a Plan that Doesn’t Cover Your Prescription Drug: What Consumers Need to Know

One of the key consumer protections in the Affordable Care Act is the requirement that plans must have a limit on out-of-pocket costs. In 2014, plans must limit out-of-pocket costs to no more than $6,350 for individuals and $12,700 for a family plan. However, there are limits on the limit, and the details matter. For one, this protection does not apply to grandfathered plans. In addition, plans do not have to count consumer spending on out-of-network care, non-essential health benefits, or non-covered services. And in 2014, employer-sponsored plans with separate out-of-pocket limits for certain benefits (for example, one for medical benefits and another for prescription drugs) have considerable flexibility in how they set their limits.

As part of our Robert Wood Johnson Foundation-funded Navigator Technical Assistance project, we received a question that falls under one of those limits on the limit. A Navigator from Georgia asked: If a patient purchases a plan through the Federal Marketplace that does not cover a specialty tier drug that the patient needs for a chronic condition, does that mean the patient is responsible for the full cost of that prescription drug, and the out-of-pocket cost will not be included as part of the patient’s out-of-pocket maximum for the marketplace plan?

Unfortunately, the simple answer is “yes” and “yes.” Plans are not required to count patient costs for a non-covered drug toward the out-of-pocket limit, which for specialty drugs can be substantial and even cost-prohibitive. However, consumers in this difficult spot have options. Under federal rules, plans that provide Essential Health Benefits must have procedures in place that allow an enrollee to “request and gain access to clinically appropriate drugs not covered by the health plan.”

Most health plans have an exceptions process for requesting coverage for non-formulary drugs. In addition, states may have requirements for what those processes must include to meet state licensing standards. In the Federal Marketplace, health plans must have an exceptions process that meets federal standards. This exceptions process is separate from the ACA-required process for appealing a benefit denial.

The federal standards note that plans can use their existing exceptions processes, as long as they allow a consumer to request both an internal review by the plan and an independent review of the exception request. If it doesn’t allow for both, CMS “encourages” health plans to use a CMS-outlined process that includes both an internal review and an independent review, with detailed timeframes for quick turnaround of a response to the request, particularly where a consumer’s health condition requires a timely answer.

Federal rules also suggest plans follow Medicare Part D guidelines for determining whether a drug is clinically appropriate. Under those guidelines, a drug is clinically appropriate and should be covered if the consumer’s prescribing physician has determined that the alternatives available to the consumer – other covered drugs, the same drug in a different dose, or an alternative drug that must be tried first – would be ineffective, cause harm, or affect patient compliance with the prescription treatment.

And finally, CMS strongly encourages plans to allow the consumer to have access to the medication in dispute as the exceptions process is underway, and, if coverage is granted, to continue to allow the consumer access to the drug in future plan years if they remain enrolled.

Of course having an exceptions process does not ensure patients will ultimately gain access to non-formulary drugs. But having such a process makes access at least possible, with the potential added benefit of lower costs and inclusion in the out-of-pocket limit.


  • Kathleen Jimenez says:

    I need a drug that is back ordered and no one knows when it will be available. It is the generic of Trusopt, which I had been taking for about 20 years. No generic but Trusopt is available, but it is not on BCBS accepted drug list. Can my PCP send in a script for Trusopt even if the insurance company does not approve it?

    • Hi Kathleen. Your doctor can write the prescription, but before you fill it, you should check with your insurer to see whether they will cover the cost, or at least part of the cost. Depending on your plan, your insurer may have a prescription drug exceptions process, which allows you to get coverage for a prescription that’s not normally on your insurer’s formulary. There are conditions for this, probably spelled out under the terms of your plan. Your doctor will likely need to weigh in as well. Good luck!

      • Scott says:

        Hi Kathleen,
        Quick question. My wife has an insurance plan through her work (public school teacher) but they offer no medications for asthma under $235 for a 30-day supply and most are around $500. It just seems to me that they should offer at least one affordable medication. Any suggestions? Thanks,

  • Reba says:

    If I am using a market place plan, and my Rx is still cost prohibative, can I use a drug discount card and pay cash for that Rx ? (For example: my % of Lyrica is $150 a month. If I se the discount card, I could pay as little as $25.)

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The opinions expressed here are solely those of the individual blog post authors and do not represent the views of Georgetown University, the Center on Health Insurance Reforms, any organization that the author is affiliated with, or the opinions of any other author who publishes on this blog.