What To Know About Getting Your 

Prescription Drugs

Health plans will help pay the cost of certain prescription drugs. You may be able to buy other 

drugs, but drugs on your plan’s “formulary” (drug list) usually will be less expensive for you.

Does my new insurance plan cover my drugs? 

To find out which drugs your Marketplace plan covers: 

n Visit your insurer’s website to review a list of drugs your plan covers.

n See your “Summary of Benefits and Coverage,” which is also

available in “See Plans Before I Apply” on HealthCare.gov.

n Call your insurer directly to find out what’s covered, and have your plan

information available. The number is on your insurance card, the insurer’s website, 

and HealthCare.gov. 

n Review any coverage materials that your plan sent to you.

My new plan doesn’t cover a drug I take. What do I do?

Even if they don’t cover a drug you take, some insurers may allow a one-time refill for a 

prescription drug after you first enroll. Ask your insurer if they allow a one-time refill until you 

can discuss next steps with your doctor.

If you can’t get a one-time refill, you have the right to follow your insurer’s drug exceptions 

process, which lets you get a prescribed drug that’s not normally covered by your health plan. 

Because the details of every plan’s exceptions process are different, you should contact your 

insurer for more information. 

Generally, to get your drug covered through the exceptions process, your doctor must confirm 

to your health plan (orally or in writing) that the drug is appropriate for your medical condition 

based on one or more of the following: 

n All other drugs covered by the plan haven’t been or won’t be as effective as the drug 

you’re requesting. 

n Any alternative drug covered by your plan has caused or is likely to cause side effects 

that may be harmful to you.
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September 2015

n If there’s a limit on the number of doses you’re allowed:

• That allowed dosage hasn’t worked for your condition, or

• The drug likely won’t work for you based on your physical or mental makeup. For 

example, based on your body weight, you may need to take more doses than 

what’s allowed by your plan. 

If you get the exception:

n Your health plan generally will treat the drug as covered and charge you the 

copayment that applies to the most expensive drugs already covered on the plan.

n Any amount you pay for the drug generally will count toward your deductible and/or 

maximum out-of-pocket limits.

Can I get the non-covered drug during the exceptions 

process?

While you’re in the exceptions process, your plan may give you access to the drug you and 

your doctor asked for until a decision is made. 

My insurer denied my request for an exception. Now what do 

I do?

If your health insurance company won’t pay for your drug, you have the right to appeal the 

decision and have it reviewed by an independent third party. To learn more about the appeals 

process, read “Appeals: eligibility and health plan decisions in the Health Insurance 

Marketplace.” 

Can I go to my regular pharmacy to get my prescription 

drug?

Just like different health plans cover different drugs, different health plans allow you to get 

your prescription drugs from different pharmacies (called “in-network pharmacies”). Call your 

insurer or visit their website to find out whether your regular pharmacy is in-network under 

your new plan and, if not, what pharmacies in your area are in-network. You can also learn 

whether you can get your prescription sent to you in the mail.

Call 1-800-318-2596 if you have additional questions. TTY users should call 1-855-889-4325.