What if Your Insurance Plan Doesn’t Cover Prescription Drugs

No Drugs Plans

In a world of ever-changing medical care, insurance plans might not always cover certain aspects of health such as prescription drugs. This could be a result of someone not feeling the need to have prescription drug coverage, or maybe they can’t afford it.

Whatever the reasons, it’s important to note that insurance coverage rules can vary from state to state. There are several ways that health plans cover prescription drugs if you do opt for that type of coverage: Copays, coinsurance, prescription deductible, integrated deductible, out-of-pocket maximum.

This article will discuss prescription drug coverage, or lack of, and how you can get find a plan that works for your needs.


Prescription drug spending in the United States grew to nearly $370 billion in 2019, “accounting for nearly 10 percent of total health expenditures,” according to Very Well Health.

Of course, the pandemic likely had a huge effect on these numbers, as more adults found themselves focusing their attention on the health and medical industries due to the financial and medical crises.

In addition, the CDC said that 48.6 percent of adults had used at least one prescription drug within 30 days, with 24 percent having used three or more, and 12.8 percent having used five or more.


  • The average increase for generic drugs is in the range of 15% annually.

According to the Organization for Economic Co-Operation and Development, Americans spend, on average, about $1,200 each year on prescription drugs. The most popular prescription drugs range in cost from $12.41- $97.57.

You can read more about the cost of prescription drugs in this article.

Given the cost of prescriptions, it’s clear that prescription drug coverage is a significant part of a comprehensive health insurance plan. But as drug prices rise, many insurance companies have put more restrictions on what they will and will not cover.

That means that even Americans who are enrolled in a plan with prescription drug coverage may incur substantial out-of-pocket costs.


Several factors affect the cost of prescription drugs, including generic or brand-name prescriptions, where you get your prescription filled, and how long you are on the medication.

Read the complete article on Very Well Health to learn more about this topic.


According to Harvard health economist and primary care physician Ben Sommers, “There’s more and more evidence that having health insurance really does improve people’s health, and medications are one of the key parts of that because it is a mainstay of how we manage a lot of chronic conditions.”

But having health insurance doesn’t mean easy access to the needed drugs.

The majority of Americans have health insurance that includes coverage for prescription drugs. But unfortunately that doesn’t ensure that they can afford the specific drugs their doctors prescribe for them, according to an article published by NPR.

This same article highlighted one poll that was released on income inequality: “Many Americans report that their insurance plans sometimes don’t cover a drug they need — and nearly half the people whom this happens to say they simply don’t fill the prescription.”

Continue Reading: When Insurance Won’t Cover Drugs, Americans Make ‘Tough Choices’ About Their Health

So, what happens when an individual’s insurance doesn’t or won’t cover prescription drugs? Well, the individual simply doesn’t buy or take their medication.

In fact, there are experiences of individuals with Medicare who pay for supplemental insurance policies just to cover the cost of the needed drugs — and that’s just for the generic version which typically results in lower quality, less-than effectual results, and out-of-pocket expenses.

For those who prioritize prescription drugs over everything else, there are resources or ways to hone in on this type of coverage.


While it might be tempting to just give up on trying to get prescription drug coverage, experts say that isn’t the route that should be taken.

“Patients struggling with their health may not understand or have the ability to push back when an insurance company sends a denial,” says Frederick Isasi, director of the consumer advocacy group Families USA. So here are different ways to get prescription drug coverage.

 Prescription Assistance Programs: 

Prescription assistance programs help patients pay for the medications at an affordable rate. Pharmaceutical companies create them to provide free or discounted prescriptions for those who need them. Patients usually have to apply to receive assistance.

 Call different pharmacies: 

As stated above, you will oftentimes find that different pharmacies will offer various rates of the same prescription. Therefore, before choosing a pharmacy, you may want to call around to see which pharmacy offers the best price.

 Ask for a 90-day supply: 

While a 30-day refill option is usually the most common, a study found that getting a 90 day supply of medication can save patients a significant amount of money. However, this option is only appropriate if you are taking maintenance medications.

 Use coupons: 

Before purchasing your prescription, you can look around for coupons that will save you money. One way to do this is by using MiraRx, where you can look at discounts from different pharmacies in your area and choose the best price.

Standalone Prescription Drug Coverage (Medicare Part D):

Medicare Part D is a type of insurance plan that Medicare beneficiaries purchase to supplement Original Medicare (or to supplement a Medicare Advantage plan that doesn’t already come with built-in Part D coverage.

The plans are called “stand-alone” because they’re purchased on their own, separate from the rest of the person’s health coverage; similar to what was addressed previously, this option is common for an Original Medicare beneficiary, resulting in a Part D plan from one insurer and a Medigap plan from a different insurer, according to the Health Insurance online organization.

You might also hear someone refer to stand-alone prescription drug coverage for people who aren’t enrolled in Medicare, although that’s much less common.

Some things to keep in mind:

  • Original Medicare is the only major type of health coverage that doesn’t include prescription drug coverage, requiring enrollees to purchase supplemental stand-alone drug coverage.

Medicare Part D is true insurance, but in most other cases, if people are buying stand-alone drug coverage, they may be getting a prescription discount program rather than an actual insurance plan.


3 Questions For Your Doctor

medical insurance
Health insurance is a vital aspect of our health and well-being. And the exponentially rising cost of healthcare is insurmountable without some level of insurance. So, it is crucial that we are covered in the case of an unforeseeable ailment or injury. However, health insurance is a complicated web of pure confusion. It takes an expert, someone who has devoted their entire career to the subject, to fully understand its ins and outs. And while you do not need to comprehend every aspect of insurance or even your own coverage completely, there are some things you’ll want to be sure are made clear.
If you’ve recently moved or required specialized medical attention, you may be seeking a new primary physician. And in this process, you’ll need to consider a few questions. To help you better understand your insurance, your doctor, and choose the best avenue of care for your needs, know what questions to ask your physician’s office. These will help you know what is covered by your insurance plan and what to expect in costs before you even book an appointment. Take out the guesswork and surprises, and take hold of your health care!
Health Insurance Concept - Doctor in hospital with health insurance related icon graphic interface showing healthcare people, money planning, risk management, medical treatment and coverage benefit.

Three questions to ask your doctor: 

1. Is this office covered by my current health insurance plan?

You can answer this inquiry in more than one way. You can simply call the office directly and ask. However, this might turn into quite a few phone calls to random doctors’ offices. Or you can check your health plan’s website for a provider directory. This may be a more direct and easily navigable solution. Also, check if your plan requires prior authorization before your visit. This will avoid charges that could otherwise be applied to your plan.

2. Does my health plan cover my healthcare requirements?

There are several essential health benefits covered by all private health care plans. These include prescription drugs, emergency visits, pregnancy, maternity, and newborn services. However, beyond these, each plan is a bit unique in its coverage. If you have questions about what particular services are covered, you can reach out to your plan for answers.

3. What will I be charged?

While you are free to visit an out-of-network provider, you’ll save the most money with someone who is in-network. This indicates that their office accepts your insurance, resulting in a smaller out-of-pocket fee. As discussed above, each plan is a bit different from the next. So avoid any unwelcome surprises and learn which services aren’t subject to your plan.
Insurance and finding a healthcare provider who is both in-network and compatible with your preferences and needs, can be a headache. That’s why we at Bernardini and Donovan are here for your insurance inquiries and navigation. Don’t go it alone- this is a complicated topic! So leave it to the experts. We’ll assist you in this process, finding the best options for your exact criteria.

New Year, New You

New Year, New You

New Year, New You

‘Tis the season of the new year’s resolution! Many people will start the new year with plans of how to improve their life. Here are a few resolutions that we would like to recommend:


One of our most significant assets in life is our time. Everyone is given the same amount of it every day. But what matters is what you do with that time. At the end of every year, it is easy to reflect back and realize that much of your time was spent doing things that don’t matter. Instead, we suggest doing this reflection much earlier. At the end of each day, at lunchtime, as you wake up, reflect over your last few hours. Think about what was important, what added something to your life and goals, and what detracted. What made you a better person and what was a waste of time. What can you do differently in your next few hours so that your precious time is used wisely?


Be your best you
For some of you, this may sound like “I want to drop 20 pounds” or the even more ambiguous I want to lose weight. Some will add the more positive spin saying “I want to eat healthier” or “Workout more.” While these are excellent goals, we want to point out that health looks different on every person. We all have our unique chemistry and genetic health history that causes us to need different markers for health. One of the best things you can do is go to your doctor and speak about what you would like. They can help you formulate different diets, exercise plans and offer you various options that are better for you than what your friend Sally did that worked for her. If you need help getting in to see a doctor, that’s where we can help. Its open enrollment right now and we can help you find an insurance plan that will let you see the doctors you want for a price that works for you. We hope that your New Year’s is terrific and that 2018 brings in the opportunities to be your best you.

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