ABC's: THE BASICS

Coverage Classroom

How Insurers Limit the Use of Medicines

Insurance Limitations

When selecting health insurance coverage to suit you and your family’s needs, you may think it is safe to assume your plan will help cover the medicines prescribed by your doctor. This, however, is not always the case. Beyond making sure the treatment you need is listed on an insurance company’s list of covered medicines or formulary, there may be additional steps insurers require before you can get the medicine you were prescribed.

This video walks through terms like step therapy or fail first and prior authorization. These are processes your insurer may require you to complete before covering the medicine your doctor prescribes. In instances where you and your doctor have already determined that a different medicine doesn’t work, this can be an added burden. And even after your insurer agrees to cover a medicine, you may be responsible for additional out-of-pocket costs.

This is another example of challenges you may face when trying to access the medicines you need.


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