Does my Health Insurance Plan cover the cost of my drugs?
Each health insurance plan has a list of all their covered prescription drugs. This list is called formulary drugs. A drug formulary is a listing of prescription medications in different categories that determines how much you will pay for the medication. If a medication is “non-formulary,” it means it is not included on the insurance company’s “formulary” or list of covered medications.
Note that formulary drugs list may change annually by the health insurance carrier. We recommend that you check with your insurance agent annually during Open enrollment to make sure your drugs are still on formulary.
Drugs Plan’s Tiers
Your health plan’s formulary is divided into 4 or 5 categories (tiers). These categories are called tiers. Drugs are placed in tiers based on the type of drug: Preferred Generics, Generics, Preferred Brands, Non-Preferred, Specialty The table below summarized the different tiers. Your health plan Schedule of Benefits or Summary of Benefits (SOB) shows your copays or coinsurance by each tier.
Tier
Drug Type
You Pay
Types of Drug Coverage:
There are different types of drugs coverage. ACA (Affordable Health Act) plans cover prescription drugs coverage. ACA plans offered by different health insurance carriers may have difference formulary drugs list.
Employer or Small Business Health Plans:
Health insurance plans offered by employers usually have prescription drugs coverage. Your employer may request to add certain medication to the plan’s formulary. Small business health insurance plans follow the ACA rules and do not deny coverage based on preexisting health conditions.
Marketplace Health Insurance Plans:
These health insurance plans are offered on and off the exchange via different health insurance carriers. The marketplace plans have difference coverage and formulary drug list than commercial or small business health plans. You can check the plans’ summary of benefits to find the coverage and cost of your medications. A health insurance agent may be able to assist you find a health insurance plan that covers your prescription drugs and providers. Click here to learn more about available marketplace health insurance plan in your state.
Medicare Drug Coverage (Part D):
Medicare Part A and Part B do not cover the prescription drugs. While Medicare Part B covers infusion mediation, Part B does not cover prescription medications. To get drugs coverage you need to enroll in a standalone Part D (Prescription Drugs Plan). There are different insurance carriers that offer Medicare Part D plans. You can consult with your insurance agent to learn more about the different plans rates and coverage.
In addition to the different plans formularies and coverage, Part D plans have 4 phases of coverage. We recommend that you always consult with your insurance agent before choosing or enrolling in a Part D plan.
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What if my Medication is Not Covered?
Letter of Medical Necessity or Appeal:
If you prescription drug is not covered under your plan formulary and there is no generic alternative under the health insurance plan, your prescriber (provider) may write a letter of medial necessity as an appeal to the insurance company. This letter is potentially reviewed by the health insurance plan and may or may not be granted.
Patient Assistance Programs:
These programs are available to assist clients pay for the high cost of specialty medications for patients who are uninsured, underinsured, or their health plan doesn’t cover the medication. The eligibility to the patient assistance programs varies between different available program and in difference states.
Copay Assistance Programs or Rebates:
Copays assistance programs are manages and maintained by the drug manufacturing companies or the pharmaceutical companies. The program is intended to assist the patients cover the deductible for the specialty medication or lower their copays. Some copay program lower the copay of a specialty medication to almost $0 a script.
Note that some of these programs may not be available in certain states or not applicable for certain to insurances. For example, Medicare insured’s are not eligible to receive rebates from insurance companies toward drug coverage.
Medicaid
Each state Medicaid program has difference coverage and network of healthcare providers and hospitals. Some Medicaid plans are represented by private health insurance carriers like: Meridian, Blue County Care…etc. Just like the marketplace health plans, or commercial plans, Medicaid also have a list of formulary drugs and covered drugs. Medicaid does not cost the insured any premium. It is mandated and regulated by each state. Consult with your insurance agent if you have questions about Medicaid or call your state Medicaid office.
