Drug Not Covered – What To Do?

As I was doing this for my son, I realized that most people probably don’t know that the option exists.  It’s something called a Formulary Override.  If you are prescribed a medication that is not covered (meaning you pay full price), you can get it covered at a 3rd tier copay (less than full cost) if your physician requests it and has a legitimate medical reason for it.

So…what do you do:

1. Call your health plan and select the IVR option for pharmacy.
2. When you talk to a call center agent, ask them about your drug.  They will confirm that it isn’t covered.
3. Ask them what you need to do to get it covered (or ask them specifically for a formulary override form that your physician can fill out).
4. Get the form (or download it from their website).
5. Ask your physician to fax it into their prior authorization department.
6. They should quickly run on it for you and have you set up in the system within a few days (if approved).

Just a quick inside hint for you.