Medications Not Covered by Insurance

If you’re taking one or more of the nearly 200 drugs (see list below) that are no longer covered by your insurance company, then you need to pay the full price for these yourself unless you can find another source to help you reduce your out-of-pocket costs.

The list of covered medications by your insurance company is called a formulary so unless your medication is on the formulary list, you’ll have to pay out-of-pocket for the full price at the pharmacy. 

Insurance companies work with pharmacy benefit managers (PBMs) to review and update their formularies on a yearly basis. The PBMs have determined there are lower-cost alternatives on the drugs being excluded however you need to check with your doctor. The PBMs will typically notify you beforehand if you will be affected by these changes and may cover some items for a brief period until alternate drug therapies for you are identified.

It’s important to note that some individual insurance plans managed by either Express Scripts or CVS Caremark may have a different formulary list so talk to your insurance provider or your company’s HR manager if you have questions about your specific drug coverage.

How to afford medications no longer covered by insurance

Here are some helpful tips to help you afford your medications that are no longer covered by your insurance:

1. Ask your healthcare provider if alternative medications that are available AND on the formulary list of covered items. The PBMs should have included the alternative with the no-longer-covered notice they provide.
2. Ask your insurance provider to make an exception for your particular case. They will put in an override if your exception is approved (known as a prior authorization or PA).
3. Since it’s still open enrollment, you may have time to shop for a better plan offered by your insurance company that better covers your medications, but you’ll need to check with your insurance provider or HR manager.
4. Apply to a Patient Assistance Program to help off-set the cost of your prescriptions. Eligibility requirements apply but may be worth your effort. Many drug manufacturers offer these programs but here is a helpful list of some of the largest patient assistance programs currently available:

• Gilead Advancing Access Program
• GSK Patient Assistance Program
• Healthwell Foundation
• PAN Foundation
• Lilly Cares Foundation Patient Assistance Program
• Novartis Patient Assistance Foundation
• Novo Patient Assistance Program
• Pfizer Patient Assistance Program

• Use our discount drug card which can save you up to 80% at the pharmacy on medications no longer covered by insurance. Our discounts may even be lower than your copay or out-of-pocket costs so use our free drug pricing tool to check the cost of your prescriptions at your neighborhood pharmacy.

Here are the formulary exclusions posted by the 2 largest pharmacy benefit managers effective on January 1, 2021: