CI Eligibility: What It Means and How It Affects Your Medication Access

When you hear CI eligibility, the criteria used by insurers to decide if a drug is covered under your plan. Also known as coverage criteria, it’s the hidden gatekeeper between you and the medication your doctor recommends. This isn’t about whether a drug works—it’s about whether your insurance says you qualify to get it. Many people assume if a drug is FDA-approved, it’s automatically covered. That’s not true. CI eligibility rules vary by plan, state, and even the specific condition you’re treating. For example, a drug like PPIs, proton pump inhibitors used to treat acid reflux and GERD might be covered only after you’ve tried cheaper alternatives first. Same goes for biosimilars, lower-cost versions of complex biologic drugs. Insurers often push these first, not because they’re better, but because they’re cheaper.

CI eligibility isn’t just about cost. It’s also about proof. For drugs like rosuvastatin, a potent statin used to lower LDL cholesterol, your insurer might require lab results showing your cholesterol hasn’t responded to lifestyle changes. For anticoagulant medications, blood thinners used to prevent clots, they may demand documentation of your specific risk factors—like atrial fibrillation or recent surgery. Even pregnancy prophylaxis, preventive treatments used during pregnancy to protect mother and baby can be blocked if your plan doesn’t recognize your risk level as high enough. These aren’t medical decisions—they’re administrative ones. And they happen behind the scenes, often after you’ve already waited weeks for a prescription.

What makes this even trickier is that CI eligibility changes constantly. New rules pop up every year. A drug that was covered last year might now need prior authorization. A generic version might get pushed to the top of the list, forcing you to switch even if your current drug works fine. That’s why knowing your plan’s formulary isn’t enough—you need to understand the CI eligibility rules that control it. If you’ve been denied a drug your doctor prescribed, it’s not necessarily because it’s not right for you. It might just mean you haven’t jumped through the right hoops yet. Below, you’ll find real-world examples of how people navigate these systems, what works, what doesn’t, and how to fight back when coverage gets stuck.