What should I do if my plan doesn’t adopt policies allowing patients to obtain prescription drugs not on its formulary, and I have to pay the full price of the drug?

As with any coverage denial for an Affordable Care Act plan, you can appeal the health plan’s decision, first for a review by the plan (known as an internal appeal) and then by an independent third party (known as an external appeal). The plan must notify you of their decision regarding your internal appeal within specific timeframes: within 72 hours for urgent cases, 15 days for prior authorization, and 30 days for services you have received. If you require urgent care, you can request an internal and external review at the same time, and you must receive a decision as soon as is required by your condition and at least within 72 hours of your request. Note that appeals must be made within 180 days of a denied claim for an internal review and within 60 days of the date that an insurer sent you an internal appeal decision. You should also report the issue to your state Department of Insurance. If your plan does not have to comply with the Affordable Care Act, you may not have the same rights to appeal the health plan’s decision. See the alternative coverage section for more information. (45 C.F.R. § 147.136; CMS, Internal Claims and Appeals and the External Review Process Overview, May 2022).