Often unpaid: exam fees, prescription food, drugs off the formulary
Pet insurance often pays only part of the bill for a sick visit. The exam fee, prescription food and some drugs stay with the owner: some insurers never pay for them, others pay only if a paid option is on the policy. Adding the option later usually means a new waiting period and a new pre-existing condition check.
How it works
A sick visit usually starts with an exam fee. Then come tests, treatment, take-home drugs and sometimes a diet. A policy can cover treatment and still strike out single lines of the bill. Tests, surgery and other treatment ordered at that visit can be covered. What drops out is the line for the exam, the food or the medication.
The documents do this in three ways.
- A flat exclusion. The item is on the exclusions list and there is no way to buy it back. Healthy Paws and Trupanion exclude exam fees this way. Fetch, Embrace, Pets Best and Healthy Paws exclude food this way, even food a vet prescribed.
- A paid option. The exam fee is covered only if the option is on the policy. So are take-home drugs at Pets Best and prescribed medication at Embrace. Pets Best calls these “supplemental benefits”. At Embrace the coverage must be shown on the pet’s Schedule of Insurance. Figo sells Optional Office Visit and Exam Fees Coverage. Adding the option later is costly. At Pets Best it takes cancelling the policy and issuing a new one. At Embrace the illness waiting period and the pre-existing condition check start over. At Figo coverage can be changed only at renewal, and the waiting period applies again from the date of the change.
- A narrow list. A drug is covered only if it meets the policy’s terms. Pets Best has its own formulary, a list it reviews every quarter. Healthy Paws counts as medication only drugs approved by the FDA for veterinary use. Figo’s Texas form counts drugs approved by the FDA or listed in the Homeopathic Pharmacopoeia of the United States. Fetch pays prescription-only drugs in quantities of 90 days or less; its countrywide and Illinois 0326 forms allow 180 days.
You choose the options on the day you buy, when the pet is healthy and nobody is thinking about bills. Once an illness is there, adding an option at Pets Best or Embrace restarts the pre-existing condition check, and the illness can end up outside the new cover. More in pre-existing conditions and what is in a policy.
The same forms have two narrower gaps: flu and declared epidemics, and a Fetch death benefit that does not pay for illness from age 6. Both are at the end of the examples.
Examples
| Brand | Exam fee | Take-home drugs | Prescription food | Can you add it later? |
|---|---|---|---|---|
| Healthy Paws | never | only drugs FDA-approved for veterinary use | no | no option exists |
| Trupanion | never | yes, as part of veterinary treatment | 50% of the cost counts, for up to 2 months | no option exists |
| Pets Best | only with the add-on | only with the add-on, and only from the formulary | no | only through a new policy |
| Embrace | only if on the Schedule | only if on the Schedule | no | yes, but the waiting period and pre-existing check restart |
| Figo (Texas) | only with the option | only FDA-approved or homeopathic-pharmacopoeia drugs | only with the exam option | only at renewal, with a new waiting period |
| Fetch | yes, as the “sick visit fee” | prescription-only, up to 90 days (180 in the countrywide and Illinois 0326 forms) | no | no option exists |
Healthy Paws: exam fees are never paid
Healthy Paws’ base policy (insurer Westchester Fire, form LD-50812) excludes exam fees as the very first general exclusion:
“We do not cover: a. Veterinary examination fees.”
There is no option that buys them back. The same policy excludes diets and food:
“Special diets, foods, vitamins, grooming, nail trims, shampoo and bathing;”
The policy counts as medication only drugs approved by the FDA for veterinary use.
This form is used in Texas and New Jersey with state endorsements that do not touch coverage. The Texas endorsement LD-51409 (11/18) changes only claims handling, suit limits, cancellation and governing law. The New Jersey one, LD-50807 (07/18), changes only IV.1 on misrepresentation and fraud. The Pennsylvania endorsement PI-50810 (09/24) replaces the general exclusions in full but keeps the exam fee: “We do not cover: a. Veterinary examination fees;”. Healthy Paws publishes LD-50812 as its general form, and it is the base policy in most states; we did not reopen every state’s copy.
Source: Healthy Paws, Westchester Fire sample policy LD-50812 (07/18), II.1.a, p. 1; II.4.j, p. 3. Endorsements: Texas, LD-51409; Pennsylvania, PI-50810 (09/24), §A, p. 1; New Jersey, LD-50807. Insurer page: Healthy Paws.
Trupanion: exams never, prescription food at half cost for two months
Trupanion’s policy lists exams among the things it never covers:
“We do not cover at any time or for any reason the costs, fees, or expenses associated with: I. Examinations;”
Exam fees also appear in section 6, on what the owner pays (p. 11).
Prescription food:
“50% of the cost of Prescription Food is eligible when recommended by Your Veterinarian for the treatment of Illnesses or Injuries covered by this policy for up to two months of normal feeding from the date of onset of the Condition.”
This is not “Trupanion pays half”. Half the cost of the food is the amount the deductible and the reimbursement rate are then applied to. And it lasts only up to two months from the onset of a covered condition. Food for long-term maintenance is not paid.
The same exam exclusion and two-month food rule appear in Trupanion’s samples for Illinois and Massachusetts (2019), California and New York (2020), and Pennsylvania and Ohio (v01-202309).
Source: Trupanion, Medical Insurance for the Life of Your Pet, TRU (D) 00001 (V10.201902), national sample: section 6.A, p. 11; 8.A, p. 13; 9.C.I, p. 15. Insurer page: Trupanion.
Pets Best, Illinois: exams and take-home drugs only if chosen at enrollment
In Pets Best’s Illinois sample policy (insurer Independence American, IAIC), three things are paid options: exams and office visits, take-home prescription drugs, and rehab, acupuncture and chiropractic care:
“The following supplemental benefits are available for additional premium and must be chosen at policy enrollment to apply.”
Without the option, the policy excludes these outright (5.A.6.a): “Treatments, therapies, and services described under the supplemental benefits coverage, if this coverage is not purchased at enrollment.”
Adding an option later is possible only through a new policy (4.A.2):
“You may increase coverage by adding a supplemental benefit or increasing your Annual Policy Limit, but these actions require the cancellation of your current policy and the issuance of a new policy.”
The new policy has new waiting periods, and pre-existing conditions are judged from its start:
“…if your Pet is showing signs or symptoms of a Condition at the time you request the change or during the Waiting Period, those Conditions will be considered Pre-existing to the new policy and any related claims will be denied.”
So a condition the old policy covered can become excluded. Raising the annual limit does the same.
Take-home drugs are covered only from Pets Best’s own list (2.B.2): “This coverage is limited to those items listed on our formulary of covered medications.” The general exclusion 5.A.6.l reads: “Any prescription or over-the-counter medications that are not included in our formulary of covered medications.” The formulary is a separate file on the website, and it says: “This formulary is reviewed quarterly.” Read literally, 5.A.6.l is not limited to take-home drugs. But 2.B.2 puts drugs given in the clinic in the base cover, and the formulary file says it applies to the take-home option and to Accident Only plans.
Food is excluded, prescription food included (5.A.6.o): “pet foods (including prescription pet foods)”. The same item also excludes “supplements”, although the take-home option lists supplements among what it covers.
Pets Best’s website describes drug cover differently from the policy. Its page on prescription coverage says the coverage “can be added or removed from the plan” and that online enrollment includes it by default. It does not say that adding it later takes a new policy.
The Illinois endorsement IAIC-PB10001-AE-IL does not change these clauses. Illinois has no pet insurance law. More on the Illinois page.
Source: Pets Best, Accident and Illness sample policy, IAIC-PB10001-ILL, Illinois, with endorsements IAIC-PB10001-AE-IL and IAIC-PB10001-PO-AE (06/2026): 2.B and 2.B.2, p. 3; 4.A.2, pp. 4–5; 5.A.6.a, p. 6; 5.A.6.l and 5.A.6.o, p. 7; Pets Best formulary, p. 1; Pets Best page on prescription coverage. Insurer page: Pets Best.
Pets Best, New Jersey and other states
The New Jersey sample has the same clauses 2.B, 4.A.2, 5.A.6.a, 5.A.6.l and 5.A.6.o, word for word. New Jersey’s law (P.L. 2025 c.224, in force from 1 January 2027) does not limit them: “Nothing in this act shall in any way prohibit or limit the types of exclusions pet insurers may use in their policies” (C.17:46D-6b). It requires only that any prescriptive, wellness or non-insurance benefits in the policy form be part of the contract (C.17:46D-8d). More on the New Jersey page.
The same clauses are in the IAIC-PB10001-ILL samples for Arizona, Texas (2.B.1–2, p. 3; 4.A.2, pp. 4–5; 5.A.6.a, l, o, pp. 6–7), Pennsylvania and Florida. The Florida and Pennsylvania endorsements do not touch them. California (IAIC-PBI0001-ILL 02/2023) and Washington (APIC-PBI0001-ILL 12/2015) use older forms with the same meaning: “3. New Policy: Adding any Supplemental Benefit or increasing your Annual limit will require that you cancel your current policy…”, with the formulary exclusion in section 9.
Vermont. Vermont law (8 V.S.A. §7155(g)) lets a policyholder “modify coverage amounts without having the policy cancelled and renewed”. Yet Pets Best’s Vermont sample still has the cancel-and-reissue clause 4.A.2, and a quick search found no endorsement replacing it. This looks like a conflict, but we have not checked it in depth.
Embrace: exams and drugs only if shown on the Schedule of Insurance
Embrace’s V6 terms make both items conditional:
“Physical Examination, if Coverage is shown on your Pet’s Schedule of Insurance;” … “Medication that is prescribed by a Veterinary Provider, if Coverage is shown on your Pet’s Schedule of Insurance;”
“Physical Examination” is a broad term at Embrace: “an exam, check-up, physical consultation, health inspection, office visit, office call, after-hour fee, referral, telemedicine consultation, telemedicine service fee, or recheck”. Without that coverage, the benefits clause pays none of these lines.
There is an inconsistency. The general definition of “Treatment” in the same terms starts with “any examination, consultation”. But the benefits clause makes exams conditional. In our reading, the more specific benefits clause controls. The conflict is worth knowing if a claim is denied.
Adding the coverage later costs you protection (Part VI, “Increasing Coverage”):
“…adding Physical Examination Coverage and/or Medication Coverage, or increasing the Reimbursement Percentage, the Illness Waiting Period and the determination of Pre-existing Conditions reset as of the date of the Coverage change.”
Food is excluded either way (Part IV): “Natural supplements, vitamins, and all foods, whether prescribed or not”.
Embrace uses V6 in Arizona, California, Florida, New York, Texas, Washington, Pennsylvania and New Jersey.
Source: Embrace, Pet Health Insurance V6: Part I (Physical Examination definition), Part III Benefits, Part IV Exclusions, Part VI Increasing Coverage. Insurer page: Embrace.
Figo, Texas: exams only with the option, changes only at renewal
Figo’s Texas policy (insurer Independence American) excludes exams (Part IV):
“Physical examination, including costs and/or fees for telephone consultation, unless You purchase Optional Office Visit and Exam Fees Coverage as shown on the Policy Declarations Page;”
Food is excluded in the same words as at Embrace: “Natural supplements, vitamins, and all foods, whether prescribed or not”. Prescription food is paid only if the policy has the same Office Visit and Exam Fees rider, and then under that rider’s terms. The policy counts as medication only drugs approved by the FDA or listed in the Homeopathic Pharmacopoeia of the United States.
Changing coverage later has two limits (Part VI):
“Changes to Coverage and adding or removing benefit endorsements are only allowed at policy renewal. In the event You choose to increase Your Pet’s Coverage after the Original Start Date, the Waiting Period applies as of the date of the Coverage change and any Pre-existing Conditions will continue to apply.”
The same narrow exam wording is in Figo’s 1025 forms for Arizona, Illinois and Indiana.
Source: Figo, policy IAIC_FPI_POL_AI_TX_1025, Texas: Part I (Medication), Part III Benefits, Part IV Exclusions, Part VI Changes to Coverage. Insurer page: Figo.
Figo, Pennsylvania and Washington: more than the exam is excluded
In Figo’s Pennsylvania form (IAIC FPI POL PA 0424), exams are taken out of the definition of treatment itself (definition 48):
“For purposes of this Policy, Treatment(s) does not include examinations performed by a Veterinarian or a Veterinary Provider in the course of treating an otherwise eligible Injury or Illness of Your Pet…”
Exclusion 7 is longer than the Texas one:
“…after-hour fees, emergency fees, clinical fees, referral fees, or recheck fees - unless You purchase Optional Office Visit and Exam Fees Coverage as shown on the Policy Declarations Page;”
Read in context, “emergency fees” here are the emergency surcharge for the visit, not emergency treatment. The treatment itself can be covered.
The same broad exclusion 7 is in Figo’s Washington form IAIC_FPI_POL_WA_0724.
Pennsylvania’s pet insurance law (Act 2024-19, 40 Pa.C.S. §§4701–4711) regulates disclosure, pre-existing conditions, waiting periods and renewal exams. It does not require insurers to cover exam fees. More on the Pennsylvania and Washington pages.
Fetch, Texas: food never, prescription drugs up to 90 days
Fetch does not exclude the exam fee. Its Texas sample (insurer AXIS) counts the “sick visit fee”, “The veterinarian examination cost for treating your pet’s injury or illness”, in the reasonable cost of treatment.
Prescription-only drugs are covered in a limited quantity (III.A.1.b):
“pharmaceuticals that can only be obtained by means of a veterinarian prescription to treat an illness or injury in the quantity of ninety (90) days or less;”
Food is excluded, even when prescribed (V.j):
“Food, including food prescribed by a veterinarian, to treat or prevent illness or injury.”
The Texas endorsement GPTM 100-TX 0124 A does not change these clauses. More on the Texas page.
Source: Fetch, Pet Health Insurance Policy Terms and Conditions, GPTM 050 1125 A with endorsement GPTM 100-TX 0124 A (sample 12.23.25): Definitions (Reasonable Cost(s), Sick Visit Fee), p. 5; III.A.1.b, p. 6; V.j, p. 11. Insurer page: Fetch.
Fetch, New Jersey and other states
The New Jersey form GPTM 050 PML NJ 0326 A has the same 90-day limit (III.A.1.b) and the same food exclusion (V.i). Supplements are covered only if they are listed in Plumb’s: “The supplement must be listed in the most current edition of the Plumb’s Veterinarian Drug Handbook in order for coverage to be afforded by this policy.”
The 90-day limit is also in Fetch’s forms for Arizona (countrywide GPTM 050 1125 A), California (GPTM 050 CA 0325 A), Florida, Pennsylvania and Washington (1125). The newer countrywide form GPTM 050 0326 A and the Illinois form GPTM 050 IL 0326 A allow 180 days and list “examinations” among covered costs. The New Jersey form, though also dated 0326, keeps 90 days. The food exclusion is in every Fetch form we checked.
Fetch: the death benefit does not pay for illness from age 6
Fetch’s policy includes a small “Death from an Accident, Injury or Illness” benefit (III.A.3.f). It pays back only what you paid for the pet:
“We will reimburse you for the price you paid for your pet, if your pet dies or has to be euthanized by a veterinarian during the policy period, as a result of an accident, injury or illness.”
It has a $1,000 annual sublimit. Without an original receipt, Fetch pays the local humane society adoption fee or $150, whichever is less. Among the conditions:
“We will not reimburse you if: … 4) The death is the result from an illness for any pet age six (6) years or older;”
So from age 6, only a death from an accident or injury qualifies. In our reading, euthanasia because of an illness falls under the same exclusion: the death still results from the illness. The benefit also does not pay for a death from a pre-existing condition, for euthanasia you asked for that a vet did not suggest, or for euthanasia because of a behavioral disorder.
The same wording is in Fetch’s forms for Arizona, Florida, California, Illinois, New Jersey, Pennsylvania and Washington, and in both countrywide forms. The Texas endorsement does not touch it.
Source: Fetch, GPTM 050 1125 A with endorsement GPTM 100-TX 0124 A (sample 12.23.25): III.A.3.f, p. 9.
Flu and declared epidemics: Spot, ASPCA, Pumpkin, Pets Best, Figo, Embrace
All four Texas forms below exclude treatment arising from an epidemic or pandemic declared by the U.S. Department of Agriculture. None of them says what counts as a declaration.
- Spot, ASPCA and Pumpkin (form PET-P-20000-1024, exclusion y): “Treatment arising from avian influenza; intentional slaughter by, or under, the order of any government or public or local authority; epidemics or pandemics as declared by the U.S. Department of Agriculture;”
- Figo (Part IV): “Costs for any Treatment arising from: Avian or swine flu or any mutant variation; Intentional slaughter by, or under, the order of any government or public or local authority; or Epidemics or pandemics as declared by the U.S. Department of Agriculture;”
- Embrace (V6, Part IV): “Costs for any Treatment arising from: Avian, swine, or any other type of influenza or any mutant variation; Intentional slaughter by, or under the order of, any government or public or local authority; Epidemics or pandemics as declared by the U.S. Department of Agriculture”
- Pets Best (5.A.6.r) words it more broadly: “Losses that arise from epidemics or pandemics as declared by the appropriate governmental body (e.g., U.S. Department of Agriculture).” The USDA is only one example of such a body.
Flu has its own exclusion that applies whether or not anything is declared. Spot, ASPCA and Pumpkin exclude avian influenza, Figo excludes avian or swine flu, and Embrace excludes “any other type of influenza” as well, which on a plain reading includes canine flu. Pets Best has no flu exclusion, so there a flu claim is refused only if an authority declares an epidemic. Pets Best also does not pay “additional pandemic-related surcharges” on a vet bill (5.A.6.m).
Not every state form has the epidemic clause: Spot’s Florida form drops the whole of exclusion y, and Pets Best’s California form drops the epidemic item.
Source: Spot, Texas sample, PET-P-20000-1024, exclusion y, p. 6; ASPCA, Texas sample, p. 6; Pumpkin, Texas sample policy, March 2026, p. 7; Pets Best, Texas sample IAIC-PB10001-ILL, 5.A.6.m and r, p. 7; Figo, Texas, Part IV; Embrace V6, Part IV. Insurer pages: Spot, ASPCA, Pumpkin.
What state laws say
None of the laws we checked requires cover for exam fees, drugs or prescription food.
- Texas. No pet insurance law. Pet insurance is classed as non-regulated inland marine (28 TAC), so policy forms are neither filed nor approved.
- Illinois. No pet insurance law.
- New Jersey. The law in force from 2027 says outright that it does not limit exclusions (C.17:46D-6b).
- Pennsylvania. Act 2024-19 regulates disclosure and pre-existing conditions, not which benefits a policy must include.
- Vermont. The law lets a policyholder change coverage amounts without the policy being cancelled (8 V.S.A. §7155(g)). See the note on Pets Best above.
- California, Washington and other states with the NAIC model law. These laws regulate disclosure and the definition of a pre-existing condition. They do not bar enrollment-only options or a formulary.
More in pet insurance laws by state.
What it looks like for an owner
A dog has a chronic illness. The vet examines it and orders tests, take-home pills and a prescription diet. Here is what each policy will not pay from that bill, going by the documents.
- Healthy Paws. Exam fee: no. Diet: no. Pills: only if the drug is FDA-approved for veterinary use.
- Trupanion. Exam fee: no. Diet: half its cost counts as eligible, and the deductible and your share come off that amount. That lasts up to two months from the onset of the illness. After that the diet is fully out of pocket.
- Pets Best without the options. Exam fee: no. Take-home pills: no. Diet: no. With the drug option, pills are paid only if they are on the formulary. If you decide to add the option now, Pets Best issues a new policy. If the dog still shows signs of the illness, it becomes pre-existing for the new policy.
- Embrace without exam and medication coverage. Exam fee and pills: no. Diet: no, under any coverage. If you add the coverage now, the illness waiting period and the pre-existing check start over.
Tests and the treatment itself can still be covered under the policy’s normal rules.
There are no dollar amounts in this example. The documents we read give no prices for exams, food or drugs, and we will not make them up. A chronic illness repeats these lines for years, so they matter more than a single bill suggests.
What to do
- Before buying, ask three things in writing: is the exam fee paid at a sick visit; are take-home drugs paid, and is there a list (formulary); is prescription food paid, and for how long.
- Search the policy for “examination”, “exam fee”, “sick visit”, “office visit”, “formulary”, “prescription food”, “food”, “diet”, “supplemental benefit”, “Schedule of Insurance”, “influenza” and “epidemic”. Check both the exclusions and the benefits section.
- If there are options, decide on the day you buy. At Pets Best, later means a new policy. At Embrace, later means a new waiting period and a new pre-existing check. At Figo, only at renewal, and with a new waiting period.
- After buying, check the document that lists your options: the Policy Declarations Page at Figo, the Schedule of Insurance at Embrace. If the option is not there, it is not in your policy. At Pets Best, confirm the options are actually on the policy: the website says online enrollment includes drug cover by default.
- If exam fees matter to you, note that Healthy Paws and Trupanion do not pay them under any plan. Pets Best, Embrace and Figo pay them only with an option. Fetch counts the sick-visit exam fee in the cost of treatment.
- If your pet needs a prescription diet, of the brands we checked Trupanion counts half the cost as eligible for up to two months, and Figo pays it only under its Office Visit and Exam Fees rider. Fetch, Embrace, Pets Best and Healthy Paws exclude food.
- Before filling a prescription on a Pets Best policy, check the drug against the current formulary: the list is reviewed every quarter.
- If a claim is denied, ask the insurer to name the policy provision in writing.
Why switching insurers once an illness has appeared rarely works is covered in the pet insurance trap. How to compare policies: how to choose pet insurance.
Sources
- Healthy Paws, Westchester Fire sample policy LD-50812 (07/18): PDF. II.1.a, p. 1; II.4.j, p. 3.
- Healthy Paws, state endorsements: Texas, LD-51409 (11/18); Pennsylvania, PI-50810 (09/24), §A, p. 1; New Jersey, LD-50807 (07/18).
- Trupanion, Medical Insurance for the Life of Your Pet, TRU (D) 00001 (V10.201902), national sample: PDF. 6.A, p. 11; 8.A, p. 13; 9.C.I, p. 15.
- Pets Best, Accident and Illness sample policy, IAIC-PB10001-ILL, Illinois, with endorsements IAIC-PB10001-AE-IL and IAIC-PB10001-PO-AE (06/2026): PDF. 2.B, 2.B.2, p. 3; 4.A.2, pp. 4–5; 5.A.6.a, p. 6; 5.A.6.l, 5.A.6.o, p. 7.
- Pets Best, IAIC-PB10001-ILL samples for New Jersey, Texas (also 5.A.6.m and r, p. 7), Arizona, Pennsylvania, Florida; forms IAIC-PBI0001-ILL (02/2023, California) and APIC-PBI0001-ILL (12/2015, Washington).
- Pets Best, formulary of covered medications, p. 1; prescription coverage page.
- Embrace, Pet Health Insurance V6: terms. Part I, Part III, Part IV, Part VI.
- Figo, policy IAIC_FPI_POL_AI_TX_1025, Texas: DOCX. Part I, Part III, Part IV, Part VI.
- Figo, policy IAIC FPI POL PA 0424, Pennsylvania: PDF. Definition 48, p. 5; exclusion 7, p. 8. The same exclusion 7 wording is in form IAIC_FPI_POL_WA_0724 (Washington).
- Fetch, GPTM 050 1125 A with endorsement GPTM 100-TX 0124 A, Texas (sample 12.23.25): PDF. Definitions, p. 5; III.A.1.b, p. 6; III.A.3.f, p. 9; V.j, p. 11.
- Fetch, GPTM 050 PML NJ 0326 A, New Jersey (sample 9.21.26): PDF. Supplements definition, p. 6; III.A.1.b, p. 7; V.i, p. 11.
- Spot, ASPCA and Pumpkin, Texas samples of form PET-P-20000-1024: Spot, exclusion y, p. 6; ASPCA, p. 6; Pumpkin, p. 7.
- New Jersey: P.L. 2025 c.224 (N.J.S.A. 17:46D), C.17:46D-6b, C.17:46D-8d; in force from 1 January 2027.
- Pennsylvania: Act 2024-19, 40 Pa.C.S. §§4701–4711.
- Vermont: 8 V.S.A. §7155(g).
- Texas: 28 TAC, pet insurance as non-regulated inland marine.
History
- First published