Understanding Prescription Drug Coverage

Many of us take medications to prevent health conditions from worsening. You likely wonder if your health insurance covers your prescription drug costs.

The law requires almost all insurance plans have to offer prescription drug coverage. Some plan providers aren’t required to offer prescription coverage, but nearly all do. The likelihood that your plan includes prescription drug coverage is very high.

But, how your plan covers prescriptions can vary from plan to plan and place to place. Remember to check your plan to see how your company covers drugs. Coverage can affect costs.

Certain Drugs Have Coverage and Others Don't

Doctors can often use different drugs to treat the same condition. Drugs are usually available from different drug companies and in various forms.

Some drug insurance companies prefer to cover one to two of these options. Certain drug types or brands may not have coverage under your plan.

Your company might provide you with a preferred drug list. Preferred drug lists can help you work with your doctor to choose the brand of medication that is right for you.

Don’t worry. Doctors can often work with your insurance if preferred drugs don’t work best for your condition. Your doctor might be able to help you get coverage for a medication that some plans don't always cover.

Check for Preferred Pharmacies

Like preferred drug options, many plans also have preferred pharmacy options. You may have to get your medication from specific pharmacies to have the plan cover them.

Generic vs. Name-brand Drugs

Many drugs have generic alternatives to name-brand drug offerings. These generic brands are often much cheaper for insurance to cover. So, you will likely have a lower cost out-of-pocket when you buy generic.

Co-pays and Tiered Coverage

You often have drug co-pays after your insurance pays its portion of the cost. The amount of your co-pay depends on many factors like the pharmacy, and type of drug.

Many insurance companies cover drug costs in tiers that help cover the co-pay. Low-tiered drugs are often more common drugs and usually cost the smallest co-pay. High-tiered drugs are sometimes called specialty drugs and usually have higher co-pays. But, the tier of drug isn’t the only factor that determines prices.

There are many factors that determine the cost you pay for drugs. Your doctor and your insurance company can work with you to get the coverage that you need.