Prescription drug insurance isn’t what it used to be, unlike earlier when you had generous prescription benefits, health insurances these days are paying for less than what they used to. You may be shocked at the pharmacy counter to know that you still have to pay a good amount in prescription costs despite your health insurance. Here are some of the features of health insurance that they use to pass on some or full prescription costs to you:
High deductibles: Most plans come with deductibles, where you have to pay up to a certain limit for your prescriptions. For some high deductible health plans (HDHPs), you may have to pay more than $6,000 each year in your healthcare costs.
Coinsurance and copays: There is a difference between these two terms that are often used interchangeably. Copay is a set amount of money that you will have to pay for a medication regardless of its retail price while in coinsurance; you must pay a percentage of the medication’s cost. More and more plans are moving to coinsurance instead of copayments, which means you will have to pay more for your medications.
Formulary exclusions: Plans revise their formularies and medication coverage each year, with more medications being excluded year-after-year. If your medication is excluded from your existing coverage, you may have to cash out its full price each time you get a fill.
High tier medications: Insurance plans used to have three tiers, but many plans now have four to six tiers. Medications are placed in different tiers, based on their prices. The higher the tier of a drug, the more you will have to pay for it in copayments. A Tier 1 medication which mostly includes generics, you may have to pay $10 as a copayment, for Tier 4 brand-name medications, it could be $90, or you may have to pay the full cost of the medication.
Quantity limits: Some plans may restrict you to certain quantity limits for some medications that you can purchase in a given period of time. If you need more of the medication beyond the quantity limits for your condition, you will have to bear its entire cost yourself.
Step therapy: Your plan provider may insist on a step-therapy for you where you will be required to try another, typically cheaper medication first and provide evidence to your insurer that it didn’t work before you are allowed coverage for the more expensive medication in the higher tier.
Prior authorization: A medication in the formulary doesn’t mean that it’s automatically covered. Your insurance provider may insist on the prior authorization by your doctor for the medication you require to provide you the coverage benefit, and there’s no guarantee that that you will get it. This way, your treatment may be delayed.
