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Why aren’t all drugs covered by insurance?

A is the list of prescription medications by a . The list typically has options. In addition to medications, a formulary can also include other products and technologies, such as and .

to provide enrollees access to treatments for a full range of conditions that will improve health outcomes. But when selecting these medications, insurance companies also factor in the cost of covering a particular drug.

Research by , a platform for medication savings, found that across insurance plan types. A by health plans — and those that remain are , such as .

Sometimes, a treatment that once appeared on your formulary can get removed unexpectedly during the year. Read on to see why these changes happen and what you can do if your medication gets dropped by your plan.

Key takeaways:

• A formulary is a list of prescription medications, products, and technologies covered by a health plan. The covered drugs will include brand-name and generic options. A formulary typically doesn’t cover every prescription medication that’s available on the market.
• While you may have chosen your insurance plan because of its drug list, a formulary can change at any time during the year. That means a medication you have been prescribed can be dropped from coverage.
• Drugs can be removed from a formulary for many reasons. This can happen if a new treatment or a more affordable option — such as a generic or biosimilar — becomes available.

Why is your insurance no longer covering certain medications?

There are many reasons why your insurance plan may no longer cover a medication. For each plan year, the formulary is published — usually prior to — to help consumers choose a health plan that’s best for them. What many people don’t realize is that throughout the year, the list of prescription options can be continually updated. Here are some reasons why your formulary may no longer include a medication, product, or technology:

• Newer medications have become available
• A more affordable option hit the market, such as a generic or
• An has arisen or the agency has updated a medication’s label or usage guidelines
• Clinical guidelines have changed to recommend a different treatment for a condition
• A health plan or its has with a medication manufacturer
• may have changed
• A low number of enrollees were prescribed the medication

How do you find out if a drug has been dropped?

Insurance plans are required to notify enrollees about formulary changes. This includes commercial insurance plans, (ACA) plans, plans, and plans. Medications that have FDA safety concerns, or those that are removed from the market, are taken off formularies immediately, and enrollees are informed. Otherwise, the notification must come at least is effective or when the enrollee requests a refill. Then, you are . In some cases, your health plan will continue covering a dropped drug until the end of the year.

What drugs are not usually covered by insurance?

Not all medications appear on every formulary. Certain medications are more likely to be omitted. by insurance can include:

• Cosmetic treatments, including medications for nonmedical
• treatments
• Medications not approved by the FDA for sale in the U.S.
• Over-the-counter products
• medications not used to treat other conditions, such as or including and

Why are insurance plans dropping GLP-1s?

Glucagon-like peptide-1 manage blood glucose, but some are also approved to help people lose weight. (semaglutide), (liraglutide), and (tirzepatide) treat Type 2 diabetes. But (semaglutide), (liraglutide), and (tirzepatide) are versions of those medications that are used for weight loss.

Cost management is the main reason or deciding to . An that one GLP-1 medication is medically necessary, while another is not.

GoodRx is changes and providing trend updates as they happen.

What can you do when insurance denies coverage for your medication?

If your prescription plan won’t cover a medication, that include:

• Talking to your prescriber about alternatives
• Asking your prescription plan for an exception
• Applying for a
• Reconsidering your prescription coverage during open enrollment

If you file an appeal, follow your insurance plan’s appeal process, which may include sending an as well as forms handled by your prescriber. You can by a third party if your appeal is turned down.

The may vary depending on whether you have a standalone plan or prescription coverage included in a Medicare Advantage plan.

How often can you expect formulary changes?

Formulary changes can happen at any time. Coverage changes are especially common for .

The bottom line

Your formulary is a living document that can change during the coverage year. A medication, product, or technology you need can be dropped at any time. Across insurance plans, prescription coverage is becoming less comprehensive and more restrictive.

Your prescription plan should notify you if your treatment is dropped from the formulary. When this happens, you have options. Sometimes, you are eligible for a final 60-day refill or coverage until the end of the year. Otherwise, you can talk to your prescriber about alternatives, ask your plan for an exception, or file an appeal.

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