13

My insurance told me that:

As the [drug name] is available over the counter, it is not covered by your health insurance. This would be an out of pocket expense for you.

Do health insurances never cover over-the-counter drugs in the United States?

  • 5
    It sometimes depends on the circumstances. If your doctor tells you to take one 81mg tablet of aspirin as a countermeasure against future heart attacks, it is not covered. If the doctor prescribes the same medication, it might be covered by health insurance, and the pharmacy will dispense it to you as a prescription drug, but the copay will likely be larger than what the same medication will cost you over the counter. People who encounter this issue usually don't bother getting refills of the prescription but just buy it over the counter. – Dilip Sarwate Jan 31 '17 at 17:17
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    Considering that generic aspirin is $3.64 for a bottle of 500 at Walmart (per Google just now), it'd seem like the paperwork (and your time) involved in processing the claim would come to far more than the actual cost of the product. Same would seem to be true of most OTC drugs. – jamesqf Jan 31 '17 at 20:16
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    @jamesqf There are many, many over-the-counter drugs that can get quite expensive over time. Birth control being one of the obvious examples. – Voo Jan 31 '17 at 21:39
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    @voo Where do you get birth control over the counter? – paparazzo Jan 31 '17 at 22:28
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    @Paparazzi The so-called "morning after pill" (levonorgestrel) is available OTC in the US. – Michael Hampton Feb 1 '17 at 7:50
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Health insurances are/were in fact required under the Affordable Care Act to cover certain categories of over-the-counter medications, including:

  • Birth control, including forms only available over-the-counter
  • Smoking cessation devices/drugs, including those only available over-the-counter
  • Aspirin, even over-the-counter

(See this CMS FAQ article).

Further, many insurance plans cover other OTC drugs, including various forms of prenatal and childhood supplements/vitamins (Folate and Iron supplements in particular), and most/all . See this Pharmacy Times article for additional details.

Third, many insurance plans cover some popular heartburn medications which are available over-the-counter; mentioned for example in this US News article.

In all of these cases, a prescription is still required for coverage; often, you may fill that prescription with over-the-counter medicine at the pharmacy, but you'll have to check out in the pharmacy (if in a general purpose store/supermarket).

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    Not quite sure how to refer to the ACA, given it's currently law but many of these requirements are effectively gone (as they won't be enforced)... open to suggestions. – Joe Jan 31 '17 at 19:06
  • I'm overriding the edit. It is not relevant to the post that the pharmacist can write the prescription; from a personal finance perspective the important thing is the prescription not who writes it. – Joe Nov 14 '17 at 20:20
10

"Never" is a strong word, but I've not heard of a health insurance plan covering over-the-counter drugs. Typically, they only cover medicines that are prescribed.

In addition, drugs can only be deductible as medical expenses (or considered qualified medical expenses for payment from a health spending plan such as an HSA or FSA) if they are prescribed by a doctor. The only exception to this is insulin, which is deductible even without a prescription. (See IRS Publication 502 for details.)

  • Thanks, interesting I wasn't aware that over-the-counter drugs were not deductible as medical expenses. Good thing I haven't filed my taxes yet (and bad thing I wasn't aware that I could deduct prescription drugs last year). Also, it's interesting that IRS Publication 502 distinguishes medicines from drugs. – Franck Dernoncourt Jan 31 '17 at 17:12
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    @FranckDernoncourt Just to be clear (and you'll find this out when you go through your Schedule A), medical expenses are only deductible if they add up to more than 10% of your income. – Ben Miller Jan 31 '17 at 17:15
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    @FranckDernoncourt I think that Pub 502 treats "drugs" and "medicines" as synonyms. If you look up "Drugs" in the pub, it simply says "See Medicines." – Ben Miller Jan 31 '17 at 17:16
  • @BenMiller Sounds better. – Joe Jan 31 '17 at 19:05
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    Glad you brought up the point about the HSA. OTC drugs used to be eligible expenses for HSA, but since 2011 most OTC drugs are only eligible expenses for an HSA with a prescription. Even though it's been 6 years, there are some people that still don't realize you need to ask your Dr to write you a script for the OTC drugs you take regularly (if you want to be able to expense them). – TTT Jan 31 '17 at 21:50
5

In general, insurance cover medications and procedures prescribed by a physician. There are limitations and exceptions, but that is the general rule.

Occasionally, even in an outpatient setting, a doctor will write a prescription for an over-the-counter med, often exactly so insurance will cover it, but most OTCs are less than your Rx deductible anyway.

In the hospital, of course, all medications are by doctor's orders and so are covered.

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    If there is an over-the-counter medication which you require regularly and is expensive enough to be worth the trouble, ask your doctor to write a prescription for it. Most health insurance plans will then cover it the same way they do any other prescription. – Perkins Feb 1 '17 at 2:00
2

I can't speak to the entire health insurance industry but over several decades of buying my own insurance, I have been with more than 6 insurance companies (finite sample) and not one paid for medications in OTC strength.

For example, Ibuprofen comes in 200 mg tablets OTC. Prescription doses are available in 400, 600, and 800 mg tablets so if your physician prescribes the larger dose, it's covered. Buy it OTC and it's out of pocket. Ironically, buying it OTC is often much cheaper than the prescription fee, especially when a deductible has not been met.

I'd hold open the possibility that if your employer provided a gold standard plan (not likely these days), OTC might be covered. I haven't seen it.

FWIW, if you're using a non timed release medication in tablet form and the cost of the Rx is much less than the OTC equivalent (perhaps a co-pay after meeting the deductible), ask your MD to prescribe the higher dose and cut the pill in half, assuming the lower dose is what you need. There are many medications where double the strength might only cost 25% more.

protected by Chris W. Rea Mar 6 at 12:46

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