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?
Drug pricing changes based on drug supply and demand, generics and alternatives becoming available, and changes in contracts with pharmacies. Given these factors, you may see changes in the cost of your medication each time you visit the same pharmacy AND among participating network pharmacies. If you are paying full price or a percentage of the cost of your medication, you may want to check pricing at several participating pharmacies to determine where you may get the best price.
What is a prescription drug plan?
A prescription drug plan, or pharmacy plan, is a part of your health care coverage. Prescription medications can be expensive. When you have pharmacy coverage or prescription drug coverage - your pharmacy plan may pay a portion of the costs of prescriptions your doctor or other health care professionals prescribe for you. These medications can be something you take for only a short while, like an antibiotic to treat an infection. They can also be something that you take for a longer time, like medications to treat high blood pressure, or insulin to treat diabetes.
We support pharmacy coverage by helping you:
- Order and refill your medicine
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 (or 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.
Who determines which drugs are on the covered drug list/formulary?
Changes in a drug list result from decisions made at P&T committee meetings. The P&T committee meets regularly to consider changes. These meetings ensure that the drug list is kept current. For example, if a new drug is found to be more effective than one already on the drug list, the new drug may replace the less effective drug.
A drug may also be removed from a drug list for safety reasons. The Food and Drug Administration (FDA) tracks drug safety information. The FDA issues reports about side effects, warnings or contraindications. As we monitor these reports, this may trigger a change in a drug list.
What is a tiered benefit design?
A tiered benefit design refers to a drug benefit with different copay or coinsurance levels.
For example, a three-tier benefit design is a prescription drug benefit with three different cost (or copay) levels. Each tier is based on the medication prescribed.
· At the pharmacy, you will pay the least for the first-tier prescription drugs and the most for the third-tier prescription drugs.
· Generally, in a three-tier design, the first tier covers generic drugs. The second tier covers brand-name drugs on the drug list. Second tier, brand-name drugs are preferred drugs and third tier drugs have always been referred to as Non-preferred Brand drugs and they are included in the formulary. The cost to you for third tier drugs can be significantly more than first and second tier drugs.
Why should I use a network pharmacy?
When you need to fill a prescription, it benefits you to use one of the pharmacies in that network. When you use a pharmacy not in your plan's network, you may run into some cost issues. For example, you will have to pay for 100 percent of the cost of your medication, out of pocket. You will also have to submit a claim to your health plan to be reimbursed for that medication cost. Your health plan does not guarantee reimbursement for prescriptions filled at non-network pharmacies.
Finding a pharmacy in the network is easy. Visit Find a pharmacy, where you have the option to search for network pharmacies by zip code or pharmacy name.
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.
Why do some prescription drugs need pre-authorization? Who determines which 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.
What are over-the-counter drugs?
Over-the-counter (OTC) drugs are drugs you can buy 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.
Why is it important to take prescriptions as directed?
The directions on prescription drugs are designed to help you get better by treating your condition most effectively. If you have questions about your prescription medication, talk with your doctor or pharmacist.
When you take your prescription drugs as directed, you can feel better faster, have less chance of a relapse of your condition and likely prevent your condition from getting worse. If you are taking a prescription medication and start to feel better before you finish the directed dosage and usage, don't stop taking it. Even though you feel better, the medication may not have finished doing its job. The condition may come back, get worse or even cause you to develop a new condition. Also, any condition that you don't effectively treat now could negatively impact you later.
It’s also important to find out if your prescription drugs react with other drugs you take. Prescription and over-the-counter drugs, vitamins and herbal supplements all can cause side effects. Some combinations of drugs, vitamins and even food can cause side effects. Some can even 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.
How is a prescription filled?
What happens after you give your prescription to the pharmacist? The pharmacist and the pharmacy technician work together to provide you with safe and efficient pharmacy services. Six quality steps are included:
- Assess. The pharmacist assesses if the medication is correct for you. For example, there are some medications one patient would take that would not be appropriate for another. The pharmacist also checks the strength of the dosage and the length of prescribed use. The assessment is finished when the pharmacist decides that the prescription is appropriate based on the information available to them.
- Enter. The pharmacist or pharmacy technician enters your prescription and insurance information into the computer. This information includes your name and address, your doctor's name, medication, directions and the reason the drug was prescribed.
- Edit. This means that your information is checked against your health plan coverage. This check verifies that you are an eligible member of your health plan. It also identifies available generic substitutes and which drugs are covered by your health plan. It checks for any drug interactions. It only takes a few seconds for the computer to check this information. The computer then sends back any edits or discrepancies for the pharmacist to address.
- Fill. The pharmacist or pharmacy technician fills your prescription.
- Check. The pharmacist does a final check of the prescription. This ensures that you are getting the correct medication and the correct dose according to your prescription.
- Consult. When you pick up your prescription, you'll talk with the pharmacist, who will explain your prescription and give you time to ask questions.
The process of filling one prescription doesn't take much time. However, some pharmacies process hundreds of prescriptions each day. Depending on prescription volume, the pharmacist and pharmacy technician might take a few minutes or several hours to complete this six-step process for your prescription.
What can I do to help lower my prescription drug costs?
Ask for a generic drug. 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.
The plan I'm looking at says I have a 3 or 6-tier benefit. What does that mean?
Usually, a plan will have different tiers, or levels of coverage for medications. You may see plans with one to six tiers. Generally, the lower the tier, the lower the cost of the medicine.
I need to take medication on an ongoing basis. Is there a way to see if it’s covered by my plan?
As you shop for a health plan, check if any medication you’re currently taking or plan to take is on the plan’s covered drug list ("formulary"), and see how much it will cost. If your medication isn’t on the drug list, ask your doctor about other options you could take, that are covered and/or consult customer service to review options and alternatives.
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.
Can I get my medication from the pharmacy down the street?
Yes. When you sign up for a plan, there will be a list of pharmacies that are in your network. These in-network pharmacies are usually able to offer covered medications and services at lower rates. You can check our Find Pharmacies tool to see if your local pharmacy is in-network for your plan. If your pharmacy isn't on the list, which is also called out-of-network, you will still be able to get your prescriptions filled there but you may pay more out of pocket for them.
How do I know what medications are covered?
Your pharmacy plan covers many prescribed medications. You can see the exact medications your plan covers by reading the drug list, or formulary. Your plan’s drug list will tell you what medications are covered and which are not, including brand-name and generic alternatives.
How does a pharmacy benefit plan work?
When your doctor gives you a prescription, you can take that to a pharmacy to be filled. Here's how your benefits are applied:
- 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.
- Because you have pharmacy benefits through your health plan, you may pay less for your medication - the amount you pay is called your cost-share. Your health plan pays the rest.
What is a home delivery?
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. Sign in to your account to see your options.
What does it mean if my prescription requires a pre-authorization?
When a pre-authorization is needed, it means your prescription drug plan must approve your prescription before it can be filled. You may first need to try a more clinically appropriate or cost effective drug before other drugs are approved by your prescription drug plan. Certain prescription medications must be tried without success before other options will be approved. We will work with your doctor to validate what drugs have been tried or why they may be inappropriate to treat your condition.
We will work closely with your doctor to determine if your prescription can be authorized. The time to make a determination depends on the urgency stated by the doctor in the request, as well as state and federal regulations. You are notified of the decision by letter.
