Under state law, this process prevents your insurer from using other ways to limit drug coverage, such as prior authorization, step therapy or “fail first” policies.
How to ask your health plan to cover a prescription
You can ask your health insurer to cover a prescription drug they don't cover or that your provider prescribed as “off-label.”
Once you or your provider request this:
- Your insurer must respond within three days unless they need more information from your provider
- If the request is urgent, your insurer must respond within one day
If you or your provider don't hear back within either time period, the request is automatically approved.
If your medication keeps you stable, your insurer must let you keep taking it until they make a decision.
Your insurer can require you to try a generic version instead of a specific brand. For drugs that treat autoimmune disorders and cancer, your insurer can require you to switch to another drug.
Your insurer can also deny an exception request for a drug the FDA removed from the market due to safety concerns.
Information you’ll need to get a drug covered
You or your provider should include information to support your request. Your health insurer must approve your request if you show that the drug they cover:
- Causes problems for you, such as bad reactions or harm
- Wasn't effective when you tried it or a similar drug
- Requires you to take a higher dosage than your health insurer allows
Your insurer can ask for additional information. This may include documents that explain how the drug they cover will affect your care, other health conditions or your ability to do daily activities.
Next steps when coverage is approved
If your health insurer agrees to cover the drug, they must tell you the cost. Health insurers can't charge you a different amount than they charge for drugs they normally cover.
Your insurer must approve refills for this drug if:
- You have a valid prescription and the Food and Drug Administration (FDA) approves the drug for treating your disease or medical condition.
- You are taking the drug as part of a clinical trial.
If you're taking an "off-label" drug, your insurer may require you to submit a new request when it's time to renew your prescription.
What to do if coverage is denied
You or your provider can ask your health insurer to change their decision. If your health insurer still denies your request, you can ask an independent review organization (RCW 48.43.535) to review their decision.
If your insurer changes their decision, they must cover what you already paid for the drug and keep covering it as long as you have a valid prescription.