QUESTION

What should I do if my plan doesn’t adopt policies to get prescriptions drugs not on its formulary, and I have to pay out-of-network charges or can’t get the drug that I need?

Post enrollment issues | Individual Health Insurance
ANSWER

As with any coverage denial, 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: with 72 hours for urgent cases, 15 days for prior authorization, within 30 days for services 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. (45 C.F.R. § 147.136).

Individuals with no coverage
Individuals with coverage
Coverage for small employers
Post enrollment issues