Insurance Limitations


When selecting health insurance coverage to suit your 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 that insurers require before you can get the medicine you were prescribed.


Important terms to know are step therapy (aka “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 isn’t right for you, 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 an example of one of the challenges you may face when trying to access the medicines you need.