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What happens if my medicine isn't on a health plan’s formulary?

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If you can't find your medicine on a health plan's drug list in your state's Marketplace, you can request that your plan cover it or give you access to it. All plans sold on the Marketplace are required to have a way to request access to off-formulary drugs.

You can request that your insurer cover a medication not on its formulary with the help of your doctor to explain the medical need. If your request is denied, you have the right to appeal your health plan's decision.

SOURCES:

The Center for Consumer Information & Insurance Oversight, U.S. Department of Health and Human Services: "Essential Health Benefits Standards: Ensuring Quality, Affordable Coverage."

Centers for Medicare & Medicaid Services: "State Pharmaceutical Assistance Programs" and "Copayment/coinsurance in drug plans."

Consumers Union and Consumers Report: "Your Health Plan’s Formulary: The List of Preferred Prescription Drugs."

FAIR Health: "Factors to Consider When Choosing a Health Plan" and "A New Look At Flexible Spending Plans."

Health Reform GPS, Robert Wood Johnson Foundation and the Hirsh Health Law and Policy Program of the George Washington University School of Public Health and Health Services: "Update: Essential Health Benefits Final Rule."

National Conference of State Legislatures: "State Pharmaceutical Assistance Programs."

FDA: "The Possible Dangers of Buying Medicines over the Internet" and "Generic Drugs: Questions and Answers."

U.S. Bureau of Labor Statistics: "Definitions of Health Insurance Terms."

Avalere Health: "Drug Coverage in Essential Health Benefits Benchmark Plans: Formulary Analysis."

American Cancer Society: "Formularies and drug coverage."

Reviewed by Sarah Goodell on February 14, 2018

SOURCES:

The Center for Consumer Information & Insurance Oversight, U.S. Department of Health and Human Services: "Essential Health Benefits Standards: Ensuring Quality, Affordable Coverage."

Centers for Medicare & Medicaid Services: "State Pharmaceutical Assistance Programs" and "Copayment/coinsurance in drug plans."

Consumers Union and Consumers Report: "Your Health Plan’s Formulary: The List of Preferred Prescription Drugs."

FAIR Health: "Factors to Consider When Choosing a Health Plan" and "A New Look At Flexible Spending Plans."

Health Reform GPS, Robert Wood Johnson Foundation and the Hirsh Health Law and Policy Program of the George Washington University School of Public Health and Health Services: "Update: Essential Health Benefits Final Rule."

National Conference of State Legislatures: "State Pharmaceutical Assistance Programs."

FDA: "The Possible Dangers of Buying Medicines over the Internet" and "Generic Drugs: Questions and Answers."

U.S. Bureau of Labor Statistics: "Definitions of Health Insurance Terms."

Avalere Health: "Drug Coverage in Essential Health Benefits Benchmark Plans: Formulary Analysis."

American Cancer Society: "Formularies and drug coverage."

Reviewed by Sarah Goodell on February 14, 2018

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Under my health insurance plan, how much will I pay for medicines?

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