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How do I know if My Prescription Drugs are Covered by My Health Insurance?

Health Insurance MedicationsWhen your very well-being hinges upon the availability of one or more prescription drugs, you need to know whether the health insurance plan to which you are drawn is willing to cover their cost. While you always have the right to purchase your medication out of pocket, many of the specialty drugs in particular are priced far out of reach of the average consumer. If certain medications are essential to your health, you’ll want to choose your plan with that in mind.

Health Insurance Formularies

Despite some obvious differences, each of the various health insurers does publish a list detailing the drugs that it is willing to cover. These lists are known as formularies, and they serve to accomplish two things. In addition to spelling out the drugs for which they might agree to pay, they describe the precise conditions under which they will or will not do so.

When Circumstances Alter Cases

Every health insurer will routinely agree to cover certain medications. In some cases, however, unfriendly provisions could come into play. Insurers may insist that the drug in question be used only to treat a particular illness. Alternatively, they might agree to cover your medicine only after you have already tried and failed with one of the drugs that they’d rather have you use. A bit of preliminary research can clue you in as to each plan’s specific restrictions.

What You’ll Pay for Prescriptions

The cost of prescriptions is never written in stone. Numerous factors will play a role, and one of them has to do with the type of health coverage you purchase. When it comes to prescription drugs, most health care plans fall into one of three distinct categories.

The first type covers prescription drugs ahead of your deductible. Under this scheme, every drug falls under the purview of coinsurance or copayments that determine your personal monetary outlay. While a generic drug might require just a $20 copayment, a branded variety could cost you a good deal more.

Another type of plan will cover your prescription drug expenses only after you’ve met a yearly deductible which can, in some cases, run into thousands of dollars. Those with an essential need for prescription drugs might want to steer away from plans of this nature.

Then there are the plans with two deductibles, one of which applies only to prescription drugs. In addition to being separate from your general deductible, its upper limit is often far lower. After you’ve met your prescription deductible, your medication will cost no more than the applicable copay.

Keep in mind, however, that regardless of the type of plan you purchase, some insurers routinely limit their coverage of certain drugs and may refuse to pay for them altogether.

Drug Coverage Levels or Tiers

Some health insurance plans group prescription drugs into four or five distinct tiers or coverage levels. These would consist of:

  • Tier one. This level will always include the cheapest generic and branded drugs and require the smallest possible copayment.
  • Tier two. Since this grouping normally contains the more expensive brand-name and generic drugs, your copay will rise as well.
  • Tier three. The costlier branded formulations fall into this category. Although these will require an even higher copayment on your part, it is often possible to uncover less expensive generic or branded equivalents in the lower levels.
  • Tiers four and five. These contain the highest-tech specialty medications. Meant for the treatment of rare and serious conditions, these drugs are also the costliest.

Not all insurers group drugs in this manner. Those that do want to fix their stated percentage of contribution in the possible hope of inspiring the insured to choose a less expensive equivalent.

The Benefits of Generics

Modern-day advertising to the contrary, branded drugs are not always the only or even the smartest alternative. When compared to their more expensive cousins with the fancy names, today’s FDA-approved generic varieties work in the same ways and with equal talent. Your body won’t know the difference, but your wallet will.

Choosing Your Plan

When your choice of a health plan hinges upon its willingness to cover the medication you require, careful comparisons are vital. This can take time. Every insurer is unique in some way, and many are more so than others.

At All Kinds of Insurance, we know how important your choice can be. That’s why we do the legwork for you, using our deep familiarity with the various offerings to choose the plan that will suit you best and cover the drugs on which your health depends.

The decision is too important to leave to chance. Call All Kinds of Insurance today at 702-534-4697 and let us find the plan that suits you best.