Your health insurance plan includes a list of covered medications called a formulary. If you've ever been shocked to see how much it costs to fill a prescription, chances are your medication isn't on your prescription.
A formulary is also known as a preferred drug list (PDL). At first glance, you might think you need a decoder ring to understand it. But understanding your man's PDL can help you pay for the medicine you need at the lowest price.
Your plan list is created by a committee of doctors and pharmacists. Louise Norris, a licensed insurance broker and analyst at healthinsurance.org, said the group works together to ensure prescribing is based on safety, effectiveness and overall value. Ta.
The PDL classifies drugs into tiers, usually between three and five, based on the drug's price. Tier 1 drugs are the least expensive and are often generic versions of brand-name drugs in more expensive tiers, Norris said.
Your insurance plan may not cover every possible drug. Depends on whether the PDL is open or closed.
Use open formulary, Your health insurance policy covers any medicines approved by the FDA. „Every drug you can imagine is at some level. The worst-case scenario is that the most expensive drug is at the top,“ says Dr. Michael Botta, co-founder of direct-to-patient healthcare company Sesame.
He says a number of commercial projects are underway or very close to being underway.
In the private formulary, „there are some drugs that are not covered by medication benefits because they are not included in any tier,“ Botta says.
He said one-third of Americans are on Medicaid, the state-funded health insurance program for low-income people. Most of those plans have closed official collections.
Visit your insurance plan's website and search. It may be under tabs such as „Find a Drug“ or „Eligible Drugs.“ The following drugs may be listed in the formulary:
- Alphabetical order
- By hierarchy
- By drug type
- For each disease condition to be treated
If you can't find the drug you're looking for, call the number on your insurance card and ask, Botta says.
„You may find that your health insurance has an interactive prescription page that displays applicable drug substitutions for medications not listed on your prescription,“ says Norris. She added that if you have high levels of the medication you are taking, you may be offered an alternative medication with a lower level.
A PDL typically contains important information about coverage, such as:
- Prior authorization (PA), or whether your plan requires prior authorization to receive drug coverage.
- Step therapy (ST), which means you have to try an inexpensive drug first to see if it helps your symptoms.
- Quantity Limitation (QL), when a drug is only covered for a certain number of refills or a certain number of doses per day;
Most formulas change at the beginning of each calendar year. Before ordering your first refill of the year, check to see if your medication is still on the list, replaced with a generic, or added a new medication you need.
If you're considering changing your health insurance plan, make sure all of your family's medications are listed on their prescriptions before making your decision.
Norris said low, fixed-cost copays are common for first-tier drugs, but coinsurance (which pays a portion of the cost) applies for first-tier drugs. To reduce costs, ask your doctor if a lower tier of the drug is available.
You may wonder if generic drugs are as good as brand-name drugs. FDA-approved generic drugs have the same ingredients and are equally effective as their brand-name counterparts. Costs are lower because there is no need to repeat expensive efficacy and safety studies. Market competition is also increasing due to the potential availability of a variety of generic drugs.
Be sure to share your current prescription list with your doctor, especially if cost is a concern. Botta suggests telling customers you want the lowest-cost option that meets their needs.
In some cases, you and your doctor may need to get creative. For example, an extended-release drug may not be covered, but a standard-release version of the same drug may be. The doctor will write a prescription for the drug, which he can take at different times of the day. This can mimic the effects of sustained-release drugs.
If you need a medication that isn't on your health insurance list, your doctor can submit a prescription exception request. You may need to do this for several reasons, Norris says.
- You are allergic to the substitute listed in the recipe.
- I already tried an alternative with PDL, but it didn't work.
- Medications listed in the formulary may interact with other medications you are taking.
- Prescription drugs can cause problems due to other health conditions.
It usually takes some time for your insurance plan to add a newly approved drug to your prescription. If your doctor determines that a new drug is the best or only option for your medical needs, you can apply for a prescription exception if your health insurance has not yet begun covering the new drug.
There is no guarantee that your insurance company will grant a prescription exception. If not, you will need to go through the appeal process. It starts with an internal appeal. If that doesn't work, you can proceed with an external appeal, which will be reviewed by a third party on your health plan's behalf.
Botta says this can sometimes be an uphill battle. He advises visiting the drug manufacturer's website to look for discounted prices. Your pharmacist may also be able to suggest ways to save money.