Which prescription drugs are covered by my plan?
Since not all health plans cover all prescription drugs you need to fully understand what prescriptions are included in your plan.
What if you need a drug that is not covered in your plan?
How much are my prescription drugs costs?
What are prescription drug coverage tiers and how do they work?
How can I lower my prescription drug costs?
To begin, you have to refer to your list of prescription drugs covered by your health insurance plan- its formulary.
What’s a formulary?:
Generally, it only covers prescription drugs included in your plan.
It includes both generic and brand-name.
Depending on the drug tier you may still owe a copayment or coinsurance.
Some drugs on your plan’s formulary may be covered automatically with a doctor’s prescription. While others only under special circumstances or after you’ve tried a different, preferred drug first.
We, as your personal broker will help you fully understand your formulary and provide you with a copy, link to your carrier’s website, or number to call. Ensuring your prescriptions are covered is important before you buy a plan.
How much are my prescription drug costs?
Cost varies by several factors, specifically as to whether it’s before or after your deductible and also if it’s a speciality drug.
Drug coverage before your deductible: If your plan covers your drugs before you meet your deductible, each drug will typically have cost sharing through either a copayment or coinsurance. Your out-of-pocket costs may vary depending on the drugs you take.
Drug coverage after your deductible: Some plans do not cover the cost of prescription drugs until you meet your plan’s annual deductible.
Drug coverage after a special prescription drug deductible: Some plans may have special deductibles solely for prescription drugs. Once you meet your prescription deductible, drugs may be covered with a copayment.
If you take a certain medication that is not covered, depending on the rules of your plan, you may be able to request a coverage exception.
What are prescription drug coverage tiers and how do they work?
Drug coverage tiers is the system designed to group different kinds of drugs. Generally, prescription drugs in higher tiers may cost you more out of pocket than drugs in lower tiers.
Each insurance carrier categorizes prescriptions differently as some may have up to 5 or 6 tiers, but here’s am example of one:
Tier 1 (generic only drugs) – Drugs from tier 1 typically have the lowest copayments.
Tier 2 (non-preferred generics and preferred brand-name drugs) – Your copay for these drugs may be higher than your copay for tier 1 drugs.
Tier 3 (non-preferred brand-name drugs) – You’ll usually pay a still-higher copayment for these than tiers 1 and 2.
Tier 4 (“specialty drugs”) – These are drugs that are costly and used in treatment for rare or serious medical conditions. Tier 4 drugs will generally have the highest out-of-pocket costs.
Knowing and understanding tiers and how it relates to your specific needs is very important because it impacts your cost. The higher the tier the higher your out-of-pocket costs may be. Nevertheless, not all insurance plans use drug tiers, and not all drug tiers work the same way.
What is the Coverage Gap (Donut Hole)
There are three phases: Initial, Coverage Gap and Catastrophic. When the combined prescription costs paid by you and your insurance carrier exceed the establish initial coverage phase you enter the coverage gap where each of you will pay a coinsurance percentage for each prescription rather than a copay. Once you reach the catastrophic phase costs is significantly reduced.
How can I lower my prescription drug costs?
One way to avoid unexpected drug costs is to know what you’re buying when shopping for coverage.
Check the formulary: make sure any prescription drugs you currently take are covered before enrolling. Otherwise, your plan may not cover your medications and your out-of-pocket costs could be higher.
Understand your plan’s coverage rules: pay special attention to whether your prescriptions will be covered with a simple copay, or whether you’ll need to fulfill your annual deductible first.
Take the time to shop around: different plans cover the same medications at different costs as well as under different tiers.
Get personalized help from a licensed broker: Please contact us for assistance. Prescription drug plans and it’s formularies vary so let' us help you.
