Your prescription drug coverage will be provided through your insurance carrier's pharmacy benefit manager. Each pharmacy benefit manager has its own rules about how prescription drugs are covered. So you need to do your homework to find out how your medications will be covered—before you choose an insurance carrier.
What to Ask
Here’s a list of questions to ask each carrier you’re considering.
Tip: You can also print out the Prescription Drug Transition Worksheet (PDF) and use it to take notes.
Is my drug on the formulary?
A formulary is a list of generic and brand name drugs that are approved by the Food and Drug Administration (FDA) and are covered under your prescription drug plan. If your drug isn’t listed on the formulary, you’ll pay more for it.
How much will my drug cost?
It depends on how your medication is classified by your insurance carrier—Tier 1, Tier 2, or Tier 3. Typically, the higher the tier, the more you’ll pay.
While generics typically cost less than brand name drugs, insurance carriers can classify higher-cost generics as Tier 2 or Tier 3 drugs. This means you’ll pay the Tier 2 or Tier 3 price for certain generic drugs. You can find this information on the carrier preview sites. Or you can use the prescription drug search tool when you enroll.
Will I have to pay a penalty if I choose a brand name drug?
Because many brand name drugs are expensive, most medical insurance carriers will require you to pay the copay or coinsurance of a higher tier—plus the cost difference between brand and generic drugs—if you choose a brand when a generic is available.
Is my drug considered “preventive” (covered 100%)?
The Affordable Care Act requires that certain preventive care drugs are covered at 100% when you fill them in-network. But each insurance carrier determines which drugs it considers “preventive.” If a drug isn’t on the preventive drug list, you’ll have to pay your portion of the cost.
Will my doctor have to provide more information before my prescription drug can be approved?
Many insurance carriers require approval of certain medications before covering them. This may apply for costly medications that aren’t considered medically necessary.
Will I have a step therapy program?
If this applies to one of your medications, you’ll need to try using the most cost-effective version first—usually the generic. A more expensive version will be covered only if the first drug isn’t effective in treating your condition.
Are there any quantity limits for my medication?
Certain drugs have quantity limits—for example, a 30-day supply—to reduce costs and encourage proper use.
How do I take advantage of mail-order service?
You’ll likely need a new 90-day prescription from your doctor. Mail order can take a few weeks to establish. So it’s a good idea to ask your doctor for a 30-day prescription to fill at a retail pharmacy in the meantime.
We’ll Help You Through the Transition
After you enroll, check out things to know before your benefits start.