Healthy Habits

When Your Medication Isn’t Covered

Older man with prescription medications

Content provided by the Health & Wellness Team at GBS Benefits

Getting a prescription filled often requires some understanding of how prescription benefits work and what to do when they don’t. Navigating insurance plan requirements isn’t easy. Terminology such as deductible, copay, prior authorization, step therapy, manufacturer’s assistance program, pharmacy tourism, and Canadian mail order can be confusing and overwhelming.

There are ways to make the most of your prescription benefits and ease potential confusion and financial burdens. Understanding your prescription benefits will help prevent complications and ensure you are able to get medications without delay.

Here are some tips for understanding your pharmacy benefits.

How to avoid being prescribed a medication that is not covered.

On the website for your insurance company, you should be able to find a formulary or preferred drug list. This is a list of generic and brand-name prescription drugs and devices covered under your plan. Formularies are categorized in four tiers, from Tier 1 (low-cost generic drugs) up to Tier 4 (unique, very high-cost specialty medications).

This information should be shared with your provider when determining which medication selection would be the most clinically and financially appropriate for you. Do not hesitate to discuss prescription coverage during your appointment as many providers are well versed in coverage determinations. Most maintenance medications for high cholesterol, high blood pressure, etc. are available in generics which fall into a Tier 1 with the lowest copay.

Brand-name-only or specialty medication?

If you need to change medications to a brand-name-only or specialty medication, the process may be more complicated.

First, check the formulary to find out which medications are covered. For the medications that are covered, there may be certain requirements that need to be met first, such as trying standard generic medications, or switching to a different class of medication. If you have tried these approaches and have not met your health goals, then advanced therapies become an option. This is known as step therapy.

Prior authorizations may be required as well. Your provider and insurance company discuss the history of treatment and clinical need for the medication in question. Once approved by the insurance company, the medication should be covered for a specific amount of time, typically one year. The process would be repeated in the event you require long-term therapy after the initial authorization has expired. Utilizing generic medications, progressing through step therapy, and obtaining prior authorizations have become mainstream.

Knowing in advance if a medication is on the formulary, what tier it falls under, and any additional requirements will help you have a successful trip to the pharmacy.

What options are available for high copays?

Before filling your medication, know what your copay is going to be by checking what tier it falls under. Typically, high copay medications are brand-name with no alternative generic.

Next, investigate if copay cards are available. Manufacturer copay cards, copay coupons, or copay assistance programs help offset the price of medications to help you save on out-of-pocket costs. This is as simple as Googling “copay card” for whatever medication you’re looking for. You will be required to complete an application that includes your insurance information, so have your card handy. Once approved, print your copay coupon and present it to your pharmacy.

If you are caught off guard at the pharmacy counter, this process can be done in a matter of minutes, even on your smart phone. Be sure to understand the terms and conditions. Copay cards do expire and have maximum limits.

What if the medication is not covered but your provider feels this is the best option for therapy?

Go to the manufacturer. Pharmaceutical companies have programs available for many widely prescribed brand-name and specialty medications. This type of program is different from a copay assistance card.

An application for a full assistance program requires your personal, financial, and insurance information. Your provider is also required to complete a section of the application. Once everything is in order, the manufacturer’s review will determine your eligibility. If you are approved, you will receive your medication for free for one year.

Assistance applications may be found on the manufacturers’ websites or by asking your doctor’s office. Many specific disease clinics typically have applications on hand. Remember, this is different from the copay assistance.

Preparation is key when approaching medical and pharmacy benefits. Seek proper education and resources available through your insurance carrier, look for coupons, and ask questions. You want the best possible outcome for your health. Don’t settle for less.

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