Simplefill connects Americans who are finding it difficult, even impossible, to pay for the prescription medications they depend on to manage chronic diseases with the programs and organizations offering such help. To learn more about prescription assistance programs and how Simplefill can help you get enrolled, read below and become a Simplefill member today.
200 Medications Dropped by Insurance for 2021
Millions of Americans got an unwelcome surprise this year when they learned that the prescription medications they rely on to manage chronic medical conditions are no longer covered by their health insurance because they were dropped from their plan’s formulary.
What is a Formulary?
Every insurance plan has its own formulary—a list of covered medications, both brand name and generic. A formulary typically is divided into three to five tiers that determine how much of the cost of the medications in each tier is covered by the insurance plan and how much the insured individual must pay.
Tier 1 typically includes generic medications, which may be 100% covered and cost the insured nothing. The higher tiers are for brand name medications, which carry a co-pay or co-insurance requirement that increases by tier, with the most costly ones being in the top “premium” or “specialty” tier. (For those unfamiliar with the terms: coinsurance requires the insured to pay a certain percentage of a drug’s full cost, while a copay is a fixed amount the insured must pay per prescription.)
How Often Do Formularies Change?
Some insurance plans change their formularies annually, but that doesn’t mean there won’t also be mid-year changes, though formulary changes are not permitted during the annual election period, which begins in October. New medications may be added, and medications already listed may be moved to a different tier or dropped altogether.
Insurance plans sometimes place restrictions on certain high-cost medications as a condition for adding them to their formulary or as an alternative to dropping them. For example, the insurer may require prior authorization, which means that health care providers must provide additional information to substantiate the need for the medication. Or they may limit the amount prescribed at one time for one co-pay, or even recommend that a different, less costly medication be prescribed initially for a trial period to see if it’s an effective alternative. Any of these changes can affect what you must pay to fill your prescriptions.
Why Do Formularies Drop Medications?
The decision to reduce or eliminate coverage for a particular prescription drug is not made casually. Typically, the decision is made by a group of health care professionals including physicians and pharmacists in conjunction with the plan’s Pharmacy Benefit Manager (PBM). A number of factors can lead to a medication being moved to a different tier or dropped from a formulary, such as:
- There is an equally effective but less costly medication.
- A generic version of a brand-name medication has become available.
- There are concerns about the effectiveness or safety of a medication.
- A medication formerly available only by prescription is now being sold over-the-counter.
- The medication is prescribed for some cosmetic purpose and is not medically necessary.
The Medications No Longer Covered
The formulary decisions made by the nation’s two largest PBMs–CVS Caremark and Express Scripts–affect what the majority of Americans pay for their prescriptions. The following are the medications they dropped from their formularies in 2021.
What Can I Do If My Medication Was Removed?
You should receive a notification if a medication you take regularly is removed from your health plan’s formulary and is no longer covered. The worst case scenario is that you will have to pay its full retail price in the future. If your medication is still listed but has been moved to a higher tier, you will end up paying more for it than you were paying before that change.
If your plan’s formulary does not include a comparable drug that your health care provider can prescribe without an adverse impact on your health, you can request that your health plan continue to cover your medication even though it is no longer listed on the formulary. The prescribing physician will need to attest to the medical necessity of granting your request. Under the Affordable Care Act, there is an appeals process that may or may not produce the outcome you’re seeking.
You also might consider changing your health plan to one that includes your medication on its formulary. This may not be feasible for those insured by an employer-sponsored plan, but Medicare recipients have the option of switching plans between October 15 and December 7 each year—Medicare’s Annual Election Period (AEP).
There are certain Medicare rules that apply when a medication is dropped from a Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug Plan within 90 days of a new member’s enrollment, as well as for members living in nursing homes or other institutional settings. In these circumstances, members are covered for a temporary supply of non-formulary medications while other options are considered, such as switching to a comparable formulary medication or requesting an exception that allows continued coverage of the dropped medication.
How Can I Save Money If My Medication Was Dropped?
Let’s assume that none of the strategies discussed to this point will enable you to get insurance coverage for a specific medication you need that has been dropped from your health plan’s formulary or moved to a higher tier. What other options do you have if you can’t afford to pay the medication’s full retail price or even a higher co-pay or coinsurance rate? You have a lot of company if you find yourself in that boat.
Many patients’ finances are stretched to the breaking point by the medical expense and income implications of living with a chronic disease, such as:
- Cardiovascular disease,
- Crohn’s disease,
- Rheumatoid arthritis,
- Parkinson’s disease,
- End stage renal disease,
- Alzheimer’s disease, to name a few.
Finding some financial relief may be essential to maintaining an uninterrupted supply of the medication(s) you rely on to manage your symptoms and slow or prevent disease progression. It can also ease the stress you and your entire household may be experiencing—stress that can have an adverse impact on your health.
There are prescription discount cards that can take an average of about 30% off the retail cost of your medications. If you meet the income and other eligibility criteria, you may also be able to get prescription coverage through a government-sponsored insurance plan for the uninsured or underinsured, such as those that became available as a result of Medicaid expansion. And many people who are struggling to pay for non-formulary medications should qualify for prescription assistance from the manufacturers of those drugs.
Government-funded prescription coverage typically allows members to fill their prescriptions for only a nominal co-pay, and sometimes for no co-pay at all. Continued membership in these government-funded plans requires a periodic requalification determination.
Pharmaceutical companies that offer prescription assistance usually do so through a charitable foundation they’ve established for that specific purpose. If you qualify, you’ll most likely receive a supply of the medication you need at little or no cost for a specified period of time—usually six or twelve months, after which you’ll need to reapply and demonstrate an ongoing need for prescription assistance.
What Does Simplefill Provide?
Simplefill proudly bridges the gap between those who are in need of prescription assistance and the programs and organizations most likely to meet that need. Once you become a Simplefill member and engage with one of our patient advocates in a profiling interview, we’ll use the information you provide about your income, prescriptions, and insurance status to match your needs to the most appropriate prescription assistance options.
Get started today, and before you know it, you’ll be paying little if anything for your non-formulary medications.