Coverage and cost
Get answers to common questions below.
Why did the cost of my medication change even though everything on my plan is the same?
There are different factors that may change the cost of your medication. These changes may occur due to supply and demand, new generic drug availability or contract changes with the pharmacy.
What is a covered drug list/formulary?
This is a list of prescription generic, brand-name, and specialty drugs that have been approved by the U.S. Food and Drug Administration (FDA). If your drug is not on this list, it will not be covered. Drugs not on this list may be covered through the Substitution (Formulary Exception) Process. Visit our web site to get updated information on our Drug List.
In some cases, only certain dosages or formulations of a medication are covered. We encourage you to use our searchable formulary tool (“Find Medicines”), available on our web site or call our Customer Service team for full coverage information.
Health plans use the covered drug list to provide you with safe and effective drug therapies at reasonable costs. It’s important to talk to your doctor about using a drug on your covered drug list when possible.
Please refer to your health plan policy for more information about the terms and conditions of your prescription drug benefit. If you have questions about any of your medications, please discuss them with your doctor or pharmacist.
How are drugs selected to be on the covered drug list/ formulary?
The covered drug list/formulary is developed and maintained by the Pharmacy and Therapeutics (P&T) committee. The P&T Committee is made up of pharmacists, physicians, and community members who meet regularly to review the safety and efficacy of drugs.
What is a tiered benefit design?
A tiered benefit design refers to a drug benefit with different copay or coinsurance levels.
Drugs are classified in tiers based on their value. Each tier is assigned its own benefit (copay or coinsurance).
What is a network pharmacy and why should I use one?
A network pharmacy is a pharmacy that is contracted with the Plan to fill your Part D covered drugs. Using a network pharmacy ensures that your Part D benefits are applied correctly, and you are charged the appropriate cost-share. Medicare only allows use of an out of network pharmacy in an emergency situation. You will pay more for your drugs at an out of network pharmacy. You will be responsible for 100 percent of the cost of your prescription and will have to submit your receipt for reimbursement. Your plan does not guarantee reimbursement for prescriptions filled at an out of network pharmacy.
Why do some prescription drugs require pre-authorization?
Pre-authorization ensures that only medically necessary treatments are covered. Medically necessary treatments are safe, effective, and have the best overall value. Doctors and pharmacists at your health plan determine which drugs require a pre-authorization and base policies on the highest quality scientific evidence available as well as input from practicing experts.
How do I get a pre-authorization for my medicines?
Talk with your doctor. If you need a drug that requires a pre-authorization, your doctor will fill out a pre-authorization request form to submit to your health plan. If the request is approved, your prescription can then be filled by a pharmacy. If the request is not approved, talk to your doctor about possible medications alternatives.
What are over-the-counter drugs?
Over-the-counter (OTC) drugs are drugs for which the FDA indicates you may purchase without a prescription. You've probably heard of OTC drugs like Zyrtec® and Prilosec®. Pharmacies and convenience stores sell many kinds of over-the-counter drugs. These drugs treat a range of conditions and symptoms. Over-the-counter drugs offer relief from some symptoms. and may be more convenient to purchase than contacting your doctor for a prescription.
It's important to understand the drugs you use. You should know about how a drug you are considering for use will interact with a drug that you currently use. Prescription and over-the-counter drugs, vitamins and herbal supplements all can cause side effects. Also, some combinations of drugs, vitamins and even food can cause side effects or alter a drug's effectiveness. Be sure to tell your doctor and your pharmacist about all the drugs that you use, including over-the-counter drugs.
What can I do to help lower my prescription drug costs?
Consider switching to a generic drug, if one is available. Generic drugs are proven safe and effective by the Food and Drug Administration (FDA). A generic drug is the same as its brand-name drug counterpart in:
- Dosage
- Performance
- Quality
- Safety
- Strength
- Usage
To find out if a generic equivalent is available for your prescription drug, search by drug name under the Find Medicines link. Check your benefit plan for coverage. You can also talk to your pharmacist or your provider.
I see the letters PA, ST, and QL by a plan selection. What do these letters mean?
I see the letters PA, ST, and QL by a plan selection. What do these letters mean?
- PA stands for pre-authorization. This means that your plan has to authorize before it will help pay for certain medicines.
- ST stands for Step Therapy. Some medicines may require step therapy, which means you may have to try a different medicine to treat your condition before your plan will cover the medicine your doctor first prescribed for you.
- QL stands for quantity limits. A quantity limit defines the amount of the drug you can fill at one time and helps reduce waste and/or overuse.
How do I fill my prescription?
When your doctor gives you a prescription, you can take that to a pharmacy to be filled. First, see if your current pharmacy is in-network or find a new in-network pharmacy when possible.
- The pharmacist fills your prescription and checks with your pharmacy plan to see what your coverage is for that medication, and how much to charge you for it.
- The amount you pay is called your cost-share. Your health plan pays the rest.
What is a home delivery/ Mail Order?
If you take maintenance medications for a chronic condition, you can eliminate trips to the pharmacy and have prescriptions shipped to the location of your choice through our mail order pharmacy. You can get 90-day supplies and automatic shipments sent to any address to ensure you don’t miss a dose even if you’re away from home. Some benefit plans may require you to get your long-term medications through one of our mail order pharmacies. You can see your option(s) here.
