Refills
We send your prescription to your specified pharmacy with enough refills to last until your next visit. When you are ready for more medication, please contact your pharmacy. Once you have used all of your refills, you will need to be seen by one of our providers before we will send a new prescription.
Reasons your medication may not be covered
Prior Authorization
This means your insurance company wants to review your medical record before paying for a medication. If your pharmacy tells you a prior authorization is requires, please ask the pharmacy to start a request on Cover My Meds – a website that makes the prior authorization process easier. To obtain a prior authorization, we will need your pharmacy benefit information (Pharmacy benefit manager name, RxBIN, RxPCN, ID number, Group number). We cannot submit a request without this information – usually your pharmacy has it on file, which is why we ask them to start the Cover My Meds request.
It can take up two weeks or longer for your insurance to review the request, and if your insurance has any additional requirements (e.g., previously failed medication and lab values), they will deny the request. While the prior authorization process can be a bit of a hassle, remember, it’s your insurance company making you jump through these hoops, not us.
Not on Formulary
A formulary is a list of prescription drugs that are approved for use by your insurance plan. When a medication is “not on formulary,” it means that your insurance plan does not cover that medication. This could be due to various reasons, such as cost considerations, availability of alternative medications, or the insurance company’s evaluation of the drug’s effectiveness and safety.
If a medication is not on formulary, it usually means you’ll have to pay the full cost of the medication out-of-pocket or consider alternatives that are covered by your insurance plan. Your healthcare provider might be able to prescribe a different medication that is on your insurance plan’s formulary and works similarly to the one that is not covered.
If your co-pay is too expensive
If your drug is covered by your insurance and your cost (co-pay) is too expensive, here is what you can do:
Tier exemption
Many insurance plans categorize medications into different tiers. Typically, generic medications are in lower tiers with lower copayments or coinsurance, while brand-name or specialty drugs might be in higher tiers with higher costs.
To get this higher-cost medication covered at the lower cost-sharing rate, you can request a “tier exemption” from your insurance company. This means you’re asking the insurance company to make an exception and cover the higher-cost medication at a lower tier’s cost.
Co-pay assistance
Google “Co-pay assistance” and the name of your medication. Often pharmaceutical manufacturers have programs that assist patients with their cost for the medication. Please note that due to federal law, these programs are not available to anyone with Medicare or Medicaid insurance.
If you pay for the medication directly
If your prior authorization or tier exemption is denied, or the medication is not on your formulary, these options can help you find the best price for the medication.
GoodRx
GoodRx is a popular online platform and mobile app that helps people find prescription medications at discounted prices. Go to goodrx.com or download their app.
Cost Plus Pharmacies
If your prescription is available as a generic, a Cost Plus Pharmacy may be a good choice for you. This type of pharmacy model operates on a different pricing structure than traditional retail pharmacies. Customers pay the actual cost of the medication plus a small markup or service fee. Instead of marking up the prices of medications significantly, like traditional pharmacies often do, Cost Plus Pharmacy charges a transparent and straightforward price that reflects the actual cost of the drug plus a reasonable profit margin.
We usually send prescriptions to Mark Cuban Cost Plus Drugs – a mail order pharmacy. As they only contact patients via email, make sure we have your preferred email address on file. You will also need to create and account (click “Sign Up” button on top right of screen). You can track your prescriptions and request refills here.