medicine

Did you know your health plan can change your medicine coverage?

  • Your health plan must notify you if it removes a medicine from its formulary or limits your access to a medicine.

Your plan must continue to cover a medicine until renewal.

  • Your health plan has to continue to cover a drug until the next time your policy is renewed, even if the drug has been removed from your plan’s drug formulary.

You can appeal an adverse determination.

  • You can appeal if your health plan refuses to cover a medicine that your doctor says is medically necessary.
  • This is considered an adverse determination, meaning a utilization review agent has determined that health care services provided or proposed to be provided to a patient are not medically necessary or are experimental or investigational.

Who can appeal an adverse determination?

  • You, someone on your behalf, or your doctor can appeal the decision orally or in writing.
  • You can start the process for appealing the decision by complaining to your health plan that you are not satisfied or disagree with an adverse determination.

The appeal process must be reasonable.

  • The procedures for appealing their decision must be reasonable.
  • The utilization review agent must send you a letter saying they got your appeal, or send you an appeal form if you made the appeal orally.
  • The letter or form will explain the review process and will list the documents that you need to submit for review.

You have the right to an expedited appeal for medicine.

  • The review process must have a procedure for a rushed appeal if your plan denies coverage for a prescription or intravenous infusions that you are receiving benefits for under the policy.
  • The expedited appeal must include a review by someone who has not reviewed the case before and with the same or similar medical specialty as the treatment under review.

You have the right to an independent review for medicine.

  • You can make an immediate appeal to an Independent Review Organization (IRO) if your plan denied prescription drugs that you are receiving benefits for under the policy.

*⃣To learn more about health insurance and drug formularies, visit The Basics section of our website.