What To Do When Insurance Doesn’t Pay For Prescription | News, Sports, Jobs


Question: I picked up my medication, but my insurance didn’t cover it. What should I do?

Answer: When picking up medication at the pharmacy, it is important to remember that your prescription drug insurance does not automatically cover everything. Some medications may not be on your coverage formulary. Formulary is the defined list of medications that the insurance company will include in their coverage. Each individual company and plan has its own formulary (list of covered medications).

There are also types of medications not covered by many Medicare Part D insurance products. A few examples of these types of medications are allergy medications, vitamins, over the counter medications, 81mg aspirin, stool softeners, shampoos, toothpastes, cold medicines, hair growth, acne, weight loss and weight gain, and many others. This list of excluded medications (which is simply an example of some of the medications not included) are not required to be carried by Part D plans (Prescription Drug Plans – PDP’s) or as part of a Medicare Advantage Plan. But you may find some of the plans include these medications as an added benefit to you, even though insurance companies are not required to include them in their formulary.

Some of these excluded medications may have been covered under your previous employer plan or Marketplace plan. Each type of insurance has its own rules about formulary inclusion and exclusions.

In purchasing these types of medications, you may now have to pay full price for the medications, or maybe you can find an alternative way to get them covered. There are two commonly used tools to get these medications at a reduced cost, one is GoodRx and the other is Cost Plus Drug Company. Both of these options are NOT prescription drug insurance products, but simply companies whose goal is to save everyone money on the cost of their medications.

Using these companies to get your medication would not replace your insurance, but be in addition to your insurance coverage through Medicare Part D rules.

To find out more about GoodRx, you can use the website, goodrx.com or call at 855-268-2822. To find out more about Cost Plus Drug Company, use the website, costplusdrugs.com. Both of these companies have different business models.

GoodRx is a discount card that you use at your local pharmacy. You may find that alternative pharmacies give you better prices, so you can switch pharmacies using GoodRx as long as your doctor sends your prescriptions over to the new pharmacy.

The Cost Plus Drug Company is a mail order business. You sign up for an account on their website. Your physician will need to send your prescriptions to their website and then you can fill your medications through the mail. You will pay a cost for the medication which includes the cost of manufacturing + 15% markup +$3.00 (Pharmacy labor) + $5.00 shipping (additional fees for expedited shipping). You and your doctor decide how many pills will be filled and how long that will last you. You are not limited to a 30 or 90 day supply.

You cannot use your insurance to help pay these prescription drug costs when using either of these companies. These are alternative prescription medication services that will fill your medications outside of your insurance coverage and formulary. Using these discount drug options may cost less than your medications covered by your insurance at your local pharmacy.

There are also medications that you may decide to purchase over the counter (OTC) as they are cheaper than buying them as prescriptions. I see this often with 81mg aspirin, allergy medication, folic acid and many others.

Many of these categories of medications are relatively inexpensive, but money saved is money kept by you. Good luck and I hope you save some money.

Senior Life Matters is a community based program sponsored by Lutheran Jamestown. For questions and concerns or to reach Janell Sluga, GCMC, call 716-720-9797 or email [email protected].