Quick Insurance Terms You May Hear
If You Have Commercial Insurance
- Is the medicine on the plan’s formulary or drug list?
- Does the medicine need prior
- Does step therapy or step edit apply?
- What will you pay before and after your deductible is met?
- What costs count toward your out-of-pocket maximum?
authorization before the plan will help pay?
- Ask the plan for the exact reason. It may be a missing form, prior authorization, formulary issue, step therapy rule, pharmacy network issue, or cost-sharing question.
- Ask whether your doctor can request an exception. This may be important if the plan wants a different medicine first or says the prescribed medicine is not normally covered.
- Ask how to appeal the decision and what the deadline is if the plan says no.
- Ask your doctor’s office, pharmacist, social worker, patient navigator, or financial counselor for help with forms, clinical information, and next steps.
If You Have Medicare Part D Drug Coverage
- Having Medicare does not always mean every prescription is covered by your Part D plan.
- A medicine may be covered by Part D plans and handled differently by another.
- A medicine may be on the formulary but still have rules, such as prior authorization or step therapy.
- Your cost may change depending on the plan, tier, pharmacy, deductible, and other Part D cost-sharing rules.
- The phrase “coverage gap” can be confusing. Part D benefit rules can change over time, so ask your plan how the current Part D benefit design affects your costs for this medicine.
If you need a Medicare drug plan decision, you or your prescriber can ask for a coverage determination. You can also ask for an exception. If you ask for an exception, your prescriber must give a statement explaining why the exception should be approved.
If the plan denies the request and you disagree, you can start the appeal process through the plan. Medicare drug plan appeals have multiple levels.
- Is this medicine on my Part D formulary? If yes, what tier is it on?
- Does this medicine require prior authorization, step therapy, or another rule?
- Can my prescriber request a coverage determination or exception?
- What supporting statement or medical information is needed?
- How do I file an appeal if the request is denied?
- What is the deadline to appeal?
- Which pharmacies can fill this prescription under my plan?
- What out-of-pocket costs should I expect under my plan?
If You Are a Veteran and Receive Health Benefits Through the VA
Questions You Can Ask If You Experience a Coverage Problem
Where to Find Help
May help identify local, state, national, and cancer-specific resources for healthcare costs, transportation, lodging, food, and other needs.
May help you understand the next steps and connect you with people on your care team or in the community.
May help explain bills, insurance coverage questions, and possible financial assistance options.
May explain pharmacy messages, formulary issues, specialty pharmacy requirements, and possible next steps.
May help explain plan rules, prior authorization status, appeals, and care coordination options.
May offer education, helplines, resource searches, transportation help, lodging help, or prescription cost resources.
For people with Medicare, State Health Insurance Assistance Programs offer local health insurance counseling.
