Covered California Certified Enroller Practice Exam

What should a consumer do if their prescription drug is not covered by their health insurance plan?

1. Request a second opinion from another doctor

2. Call the health insurance company's customer service for approval

3. Switch to a different medication without consulting

4. File a complaint with the state department

The correct answer is: Call the health insurance company's customer service for approval

When a consumer finds that their prescription drug is not covered by their health insurance plan, the most appropriate step is to call the health insurance company's customer service for approval. This approach allows the consumer to directly inquire about the reasons for the lack of coverage and explore possible options for obtaining the medication. Health insurance plans often have specific formularies—lists of covered drugs. By contacting customer service, consumers can ask about the possibility of getting a prior authorization for the medication, inquire if it is covered under a different classification, or see if there are alternative medications that are covered. This is an essential first step before considering other actions, as customer service representatives can provide the most accurate and relevant information regarding the specific plan. Choosing to switch to a different medication without consulting healthcare professionals could lead to complications, such as adverse effects or interactions with other medications. Seeking a second opinion might be unnecessary if the primary concern is insurance coverage rather than a medical need for a different medication. Filing a complaint with the state department is generally a last-resort action and does not directly address the issue of the specifics of coverage, making it less effective initially. Thus, contacting the insurance company's customer service helps the consumer navigate their options more effectively.