National Consumers League

Health

NCL Health Issues

Choosing a prescription drug coverage plan

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When choosing a health plan, making sure the medicines you take regularly are covered is just as important as knowing that your doctor is in the network.

Most health plans cover prescription medicines, but the rules may be different than those for other medical services. In addition, pharmacy benefits may not be administered by the same company as the physician and hospital benefits, but rather by a separate company, called a PBM.

 

Before you decide on a prescription drug benefit plan, get the facts you need:

Find out if the health plan or PBM has a limited list of drugs it will cover. This is known as a formulary. If someone in your family takes medications for a chronic illness, such as high blood pressure, asthma, or diabetes, be sure those medicines are on the formulary before you select that plan. If they aren’t, you will be expected to switch to different medications or pay for them without insurance.

Find out how to file an appeal if the medicine you need is not covered by your insurance. If the medicine you need is not on the formulary, you usually can file an appeal with the health plan to request that they cover it anyway. You will not be notified of your right to appeal when you are denied coverage, so it is important to find how to file an appeal on your own. Your doctor will need to provide the information to explain why you need that specific medicine.

Find out how much you have to pay when you fill a prescription. Most plans require a co-payment for each prescription. Many plans have three or even four levels, or tiers, of co-payments that apply to different medicines. Find out what co-payment level applies to the medications you are taking. If it is more than you can afford, you may want to ask your doctor if there are other medicines on a lower tier that would be appropriate for you.

Find out if the health plan has to pre-approve certain drugs before you can fill the prescription. Many plans require your doctor to have “prior authorization” for some medicines before it will pay for them. That means your physician or pharmacist must call for permission to prescribe these medications. Some plans also require you to try a less expensive medicine before it will pay for the one your doctor might otherwise recommend. If you need a certain medication for a valid medical reason, you can often get it covered by filing an appeal. If you can’t wait for the appeal process to finish, you may need to pay for the medicine yourself and then file an appeal to be reimbursed by the plan.

Find out if the health plan offers a mail order option. Some plans offer a mail order service for medicines and offer incentives like lower co-payments to encourage you to use it. Other plans have mandatory mail order services and require you to order your long-term medications through the mail. The plan will not pay for them if you try to obtain them at a local pharmacy.

When choosing a health plan, making sure the medicines you take regularly are covered is just as important as knowing that your doctor is in the network. Knowing how to select the right prescription drug coverage for you and your family is important to maintaining and restoring your health.

While most insurance includes coverage for prescription medicines, the rules for pharmacy benefits are often different than for medical. For example, your prescription claims may be handled by a pharmacy benefit manager, or PBM (a company that administers a health plan or employer’s drug benefits).

Asking the right questions is key to getting the most appropriate medicines for you and your family and in limiting your costs. When making decisions, always look at the potential impact of your health plan choice on the medicines that members of your family are currently taking for a serious condition or chronic illness.

Before you decide on a prescription drug benefit plan, get the facts you need.