Understanding How Your Insurance Covers Prescription Drugs
Whether you have your health insurance through FEHB, Tricare, Medicare, Affordable Care Act, or a spouse’s group plan, prescription costs can be a concern. If you take any medication, it is important to know how your specific plan covers that medication. Most health plans will have a list of formulary drugs, which lists the prescription medication that is covered by the plan. The formulary list notates the tier of each drug and any special requirements such as quantity limits, step therapy, or prior authorization.
Prescription Plan Limitations
As a member of the insurance plan, it is important that you understand tiers, step therapy, quantity limits, and prior authorization.
- A drug tier will tell you the copay or coinsurance for each drug.
- Your copay or coinsurance is the amount you will have to pay when you pick the drug up at the pharmacy.
- Step therapy is managed care prescription drug therapies and processes that health insurers use to control prescription drug costs. You may be required to first use a less expensive equivalent before being able to use the formulary drug which your health care provider originally prescribed.
- Quantity limits can be imposed on medications to help encourage appropriate use, ensure effectiveness, and lower costs. A quantity limit is the highest amount of a prescription drug that can be given to you by your pharmacy in a period of time.
- If the plan requires prior authorization for a specific medication, that means your physician will have to receive approval from the insurance provider before the prescription of the medication. In that case, your physician will be your strongest advocate to get the medication approved.
These limitations can feel frustrating, but they help to keep drug costs and healthcare premiums low for all.
5 Ways to Lower Your Prescription Drug Costs
Even with good prescription drug coverage, the cost of medication can be a financial burden, particularly if you take name-brand medication. Here are five ways you may be able to lower your drug costs.
Ask for Generics
When your doctor prescribes a new medication, make sure to ask if the medication has a generic equivalent. Generic medications are cheaper than name-brand drugs. You have the right to let your provider know that you prefer generics before they write the prescriptions. Many common diagnoses have medications that are available in generics.
Shop Around
In addition to knowing the cost of your medications under your health plan, you can ask what the cash price is at your pharmacy. You can also check other pharmacies to see what their cash prices are. Even though you have health insurance, you can pay cash if the cash price at your pharmacy is more cost-effective. In addition to asking what the cash price is for your medication, you can ask your pharmacy if their discount plan or other online programs such as Good RX offer a better price than your health plan’s copay.
Use a Coupon
Drug manufacturers often offer coupons for their brand name medications. Check the manufacturer’s website for available savings and coupons. Typically these coupons will only work with major medical and are not compatible with Medicare Prescription Drug Plans (Part D). If you have a major medical plan, such as a group plan or FEHB, it is likely that the manufacturer coupon is compatible with your health plan.
Look for Patient Assistance Programs
Patient assistance programs provide free or lower-cost medication to people who cannot afford to buy their medication and/or fall within certain income ranges. Some patient assistance programs to check out are:
If you have a specific diagnosis you can also search the internet for a community organization that assists with that specific diagnosis. There are community organizations that assist with HIV and AIDS medications in most major cities as the drug costs for those infections are extremely expensive.
Ask for Formulary Exceptions
If you need a name-brand medication where there is a generic available, your plan may not cover the name-brand. In addition, if you are prescribed a medication that is not on the plan’s formulary, you may have to pay the full cost of the medication. In either of these scenarios, you with the assistance of your doctor can ask the plan for a formulary exception. If the plan approves the formulary exception, they will place your medication in a lower tier than normal due to your medical needs.
Just because you’ve been prescribed a medication and have health insurance, does not mean you do not have the right and ability to find the lowest price possible. Take advantage of any coupons and programs. And, have open and honest conversations with your provider about your cost concerns. Your provider is there to help you in this process.
Have Questions About How to Maximize Your Benefits?
Get in touch with a United Benefits Specialist if you have questions about Medicare Part D, FEHB benefits, or anything else. We are always here to help. Fill out the form below to get in touch.