Understanding drug insurance can be overwhelming, but focusing on key concepts and taking a few simple steps can reduce the insurance-related frustration.
Prescription drug insurance is either part of a medical insurance policy or its own separate policy. Commercial medical plans provided by employers often have a combined medical and drug insurance policy. If you are older than 65, it is common to have a separate prescription- only policy such as a Medicare Part D Plan or Wisconsin Senior care.
Since different services and products are covered under different plans, it is important to understand the coverage differences between medical insurance and drug insurance.
For example, a shingles vaccine is covered under a drug plan and administered by the pharmacist, where in some cases, certain medications or diabetic testing supplies are billed to the medical plan and not the drug plan. This example shows how coverage can be puzzling, so avoid confusion by consulting pharmacy staff and reading the insurance policies.
When reading a drug insurance policy, review the medication formulary and verify the deductible. The medication formulary is a list of covered medications separated into levels or tiers based on cost and coverage. Expensive brand medications are often placed in higher tiers and are associated with higher costs than generic medications. Formularies are different from plan to plan, and the insurance company can change them at any time, so avoid choosing an insurance plan solely on the medication formulary.
A deductible or spend-down is the amount of out-of-pocket money the policyholder is responsible for before insurance will cover a percentage of the drug cost. Overlooking the deductible can lead a person to believe a medication is not covered when the cost will be reasonable once the deductible is met.
When evaluating deductibles, formularies, and overall drug costs, it is important to ask a pharmacist for suggestions on alternative medications to better reduce medication costs.
-Elizabeth Wimmler PharmD, RPh, is a pharmacist at Glander Prescription Plus Pharmacy in Sheboygan