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Overcoming Prescription Coverage Restrictions: What to Do When You Need More Than Your Plan Allows

Written and medically reviewed by Dorcas Morak, Pharm.D

Updated on May 26th, 2023

Save up to 88% on your medications

Written and medically reviewed by Dorcas Morak, PharmD

Are you struggling to get your prescription refilled because of insurance coverage issues like quantity limits and early refill restrictions? Don't worry, we've got you covered! In this article, we will show you how to work around these restrictions and get the medication you need.

First, let's define what quantity limits and early refill restrictions are. Quantity limits refer to the amount of medication your insurance plan will cover in a specific time frame. For example, you may be limited to a 30-day supply of a particular drug. Once you finish the quantity dispensed, you will need a new doctor's prescription for a refill. Early refill restrictions occur when you request a refill before you should and your insurance plan restricts coverage.

What if I need an emergency refill?

There are many reasons you might need an emergency refill. Maybe your medication was lost or stolen or you need a backup supply. In this case, there might be a coverage restriction in place to make sure you're taking your medications as prescribed and to prevent abuse of controlled substances. But don't worry, your pharmacist can help! Your pharmacist can use their judgment - in compliance with state law - to provide an emergency refill for certain chronic conditions, up to a 30-day supply. However, if you take controlled medications, this doesn't apply. If your insurance won't cover an early refill, don't panic - check out rxless to save up to 88% without using insurance!

How can I get a quantity limit exception?

If you need to take an amount of medication that exceeds the limit set by your plan, you can apply for a quantity limit exception to exceed the limit and get the full amount of medication prescribed by your doctor. To apply, ask your doctor to submit a detailed application that explains your health issue, why the quantity limit would be harmful, and why alternative treatments are not effective. Your insurance plan will typically review the application within three days and provide feedback through your doctor or pharmacist.

What should I do if my quantity limit exception request is denied?

If you find yourself in a situation where your insurance plan denies your request for a quantity limit exception, don't despair. You still have options!

Firstly, you can appeal the decision. To do this, you will need to submit your appeal within a specific time frame (usually around 60 days). Your insurance company will then review your appeal and make a decision within 30 days. However, if you have a health emergency, you and your doctor can apply for an expedited appeal to shorten the duration to days instead of weeks.

If appealing is not an option or doesn't work out, you can also consider alternative medications. Ask your doctor if there are any generics or alternative medications that could work for you. Some insurance plans only set quantity limits on brand-name medications, not generics. This means that switching to a generic medication could be a solution for you.

How can I save money on my medications?

If you are paying for your medications out of pocket or want to avoid coverage restrictions, use an RxLess prescription savings coupon to get up to 88% off the retail price. You can use RxLess at more than 70,000 pharmacies nationwide, including Rite Aid, Walgreens, and CVS.

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