Prescription drugs are drugs and medications that, by law, require a prescription from a licensed healthcare provider before it can be filled by a pharmacy. They are different than over-the-counter drugs, which do not require a prescription and which are generally not covered by insurance.
What are prescription drugs ?
Almost all health insurance plans provide some help with paying for prescription drugs.
Every insurer will have an approved list of medicines which they refer to as the plan’s formulary. Some plans will provide no coverage for medicines not on their formulary while other plans will provide limited coverage.
Due to the high cost of some medicines, it is critical to review all your prescription needs prior to choosing a plan.
Is my prescription covered ?
Review any coverage materials that your plan mailed to you. Most insurers mail a hard copy of the formulary. It does not always arrive quickly after enrolling.
• Visit your insurer’s website to review your plan’s formulary online.
• Read your Summary of Benefits and Coverage (SBC), which you can get from your insurance company, or by visiting their website. Understand your copay amounts.
• Call your insurer directly to find out what is covered and how much you will need to pay.
Where can I get my prescription filled ?
Different health insurance plans permit you to get your medicine from different pharmacies. The insurer has contracts with some pharmacies to provide prescriptions at lower prices. These pharmacies are called “in-network pharmacies.”
Your plan documents will list the in-network pharmacies. If you cannot find that information, call your insurance company or visit their website to find out whether your preferred pharmacy is in-network or not. You can also learn if you can get your prescription delivered in the mail.
Delivery by mail is convenient and in many cases your insurance company encourages this method by offering 90-day supply and significant discounts.
♦ Don’t go this route until you are certain you will be continuing the medicine long term, otherwise you run the risk of paying for medicine you might have to throw away.
How early can a prescription be refilled ?
A refill for a 30-day retail prescription can usually be refilled no more than 7 days early and a 90-day prescription no more than 14 days early. A lot will have to do with the medication you are taking, the reason for refilling early and your insurance company’s rules.
Many insurance plans permit what is called a "vacation override." Mention to your pharmacist that you are going to be traveling out of the country on vacation and will run out of medication. A number of people report being able to refill maintenance type medications (such as blood pressure or cholesterol medications) up to 14 days early by this method.
• There have been some cases where the insurance company requested to know details related to the travel plans. This is a bit rare.
Mostly it involves a few clicks of the computer mouse at the pharmacy. Just be aware some insurance companies can throw up a few road blocks before they approve, especially if it is a very expensive medication.
♦ A narcotic or anything even remotely addicting, will be even tougher. Even prescription cough medicine is considered a controlled substance and will be regulated. If the prescribing physician did not specify an earliest refill date then there is a chance of getting a refill 2 days early.
There is an epidemic of prescription drug addiction in America. To try to combat this the Federal government has issued a number of guidelines restricting early refills. By far, it is State regulations that are proving the most restrictive.
• The major drugstore chains and pharmacist are frightened of running afoul of the law.
They may throw up road blocks like requiring written permission from your doctor to refill a controlled substance early. Talk with your doctor. He or she may be able to push through a refill or perhaps change the medication strength and you fill a new prescription.
How much do I have to pay for prescriptions ?
Traditional insurance plans use a tier system for deciding how much to pay for a drug. These are designed to require different levels for copay. The terminology used by your plan may be a bit different.
♦ The Affordable Care Act calls for a standardization of terms to help everyone better understand and compare insurance plans. This part of the act is still a work in progress.
The example below shows how prices might vary for drugs on your formulary (approved list). Your plan will have something similar.
|5||Preferred specialty drug||40% copay|
|6||Non-preferred specialty drug||50% copay|
♦ Be aware, most insurance companies are classifying some of the newer generic drugs as Tier 3. We might argue that the drug is a generic so why isn’t it a Tier 1 or Tier 2? It all comes down to cost.
Expensive brand drugs are often times quite expensive when they first become available as a generic. Initially there may be only one or two manufacturers approved to make a generic (sometimes it is even the manufacturer of the brand version).
When there is limited competition there is little incentive to bring the price down. Sometimes, the ingredients are expensive so whether it is the brand or the generic the price can be heavily influenced by the cost of the ingredients.
♦ You might think that if the generic is going have a copay close to that of a brand drug then you will just take the brand version. Insurance companies know people will think this way.
To encourage people to use the generic over the brand they may not cover the brand at all or they may treat the brand as non-preferred so the consumer is responsible for more of the expense.
It is important that you check your plan’s formulary to see how your prescription will be classified. Don't just assume that because you heard your prescription is a generic that you will pay the lowest copay.
You need to check. You can call your plan’s customer service number and ask them to tell you the price. Don’t just ask for the price this year. Ask them if anything will change next year.
♦ Your plan can adjust the formulary every year. Sometimes this can help with lowering costs but it can also result in higher costs, especially if your plan decides to not cover your particular drug next year.
It is imperative that you understand the differences between each tier if you are to keep your prescription drug cost under control. To help you better understand there is a page devoted to each: Generics, Brand-Name Drugs, Specialty Drugs, Biological Drugs
Two tiered network pharmacies
A new twist in controlling prescription drug costs is to have two prices for the same drug even when purchased from a network pharmacy. The trend is to have a "preferred" network pharmacy with a lower copay than a network pharmacy. While the both pharmacies are in the network one is classified as preferred.
• BlueCross BlueShield is offering several on-exchange plans that require a $30 copay for a preferred band-name drug when purchased at a preferred network pharmacy but a $40 copay when purchased at a network pharmacy that is not preferred.
• If you look up the price of a drug at BlueCross BlueShield's website you will see they refer to the pharmacies as Level 1 and Level 2.
Level 1 is their preferred pharmacy. Here you can receive the lower price and also a 90 day supply for some medications. To discourage use of Level 2 pharmacies supply is limited to 30 days.
Purchasing from a pharmacy that is out-of-network is not covered all. As long as your local pharmacy is on the preferred list you should be fine.
What if my plan no longer covers my prescription ?
Some insurance companies may provide a one-time refill for your medication. Ask your insurance company if they offer a one-time refill until you can discuss the next steps with your doctor.
If you cannot get a one-time refill, you have the right to ask your insurance company for an exception. If your insurance company agrees, you will be able to get the prescription covered. The process for asking an exception is different for every plan. You need to contact your insurance company for the details.
Generally, to get your drug covered through the exceptions process, your doctor must confirm to your insurance company either orally or in writing that the drug is appropriate for your medical condition based on one or more of the following:
• All other drugs covered by the plan have not been or won’t be as effective as the drug you’re asking for
• Any alternative drug covered by your plan has caused or is likely to cause side effects that may be harmful to you
• If there’s a limit on the number of doses you’re allowed:
That the allowed dosage hasn’t worked for your condition, or
The drug likely won’t work for you based on your physical or mental makeup. For example, based on your body weight, you may need to take more doses than what’s allowed by your plan.
If you get the exception:
• Your insurer generally will treat the drug as covered and charge you the copayment that applies to the most expensive drugs already covered on the plan (for example, a non-preferred brand drug).
• Any amount you pay for the drug generally will count toward your deductible and/or maximum out-of-pocket limits.
Can I get the non-covered drug during the exceptions process ?
While you’re in the exceptions process, your plan may give you access to the requested drug until a decision is made.
My insurer denied my request for an exception.
Now what do I do ?
If your health insurance company won’t pay for your prescription, you have the right to appeal the decision and have it reviewed by an independent third party. Learn more about the appeals process.