An important part of a health insurance plan is the medications it covers. When choosing a plan, you may consider any underlying health conditions you or your family members have and figure out how many prescriptions you’d need during the year.
For example, if you or a dependent have a chronic health condition that needs regular prescription medication, you may consider a plan that has wide drug coverage. Even if you have no dependents, are in good overall health, and don’t foresee a need for regular prescription medications, you may still consider choosing a plan that has thorough coverage of prescription medications.
Let’s look at how to tell if your health insurance has adequate drug coverage.
How to check your insurance coverage
It may feel overwhelming to look through health insurance documentation. You have lots to consider, from in-network and out-of-network healthcare professionals to deductibles and copayments. But knowing your coverage can help you avoid unwelcome surprises.
Check your plan details and certificate of coverage
Every health insurance plan sends a package that gives you both a general and a detailed view of benefits and services. This is often known as a certificate of coverage.
The certificate of coverage explains and details exactly what is and is not covered under your plan. The certificate of coverage is also known as:
- contract
- evidence of coverage
- summary plan description
- summary of benefits coverage
- benefit plan document
An insurance provider will give you the certificate of coverage for free once you enroll in one of its plans. You can also request online access.
The certificate of coverage will list medication coverage under a drug formulary, or drug list. It will also list any applicable out-of-pocket expenses, including for medications.
Plus, you’ll find information on any services, benefits, and medications that are not covered (known as exclusions), as well as the requirements you need to meet to get certain benefits, like meeting a deductible, paying a copayment, or visiting approved or in-network healthcare professionals.
Some certificates of coverage also inform you about the process of appeal in case a service or medication you need is not covered.
Check for add-on plans
Add-on options are benefits you can add to your existing and primary health plan at an additional charge. The list of add-on plans depends on the healthcare insurance company and plan you have chosen.
Add-on plans usually include extended hospital stays, accident insurance, and prescription medication coverage. These plans are also called rider options or supplemental plans.
People with Medicare have the choice of joining a prescription medication plan, covered under Medicare Part D. People who have employer- and union-provided insurance can also opt to have Medicare Part D. The list of prescription medications Part D covers is under each plan’s drug formulary.
What to know about drug formularies
Formularies are a list of medications covered by a health insurance plan.
Formularies are also known as:
- drug list
- preferred drug list
- prescription drug list
- medication coverage list
Formularies typically list medications in drug tiers, or levels. These tiers are divided mostly depending on the medication’s cost. The lowest tier is made up of generic and lower cost medications.
Each insurance plan has its own formulary or drug list, which could have set copays for each tier. The copay for higher tier medications is the highest and will vary by plan.
You can look at your plan’s formulary to see whether the medication you need is covered and how much your copayment would be.
Why might insurance not cover some medications?
Some insurance plans won’t cover certain medications for several reasons, such as:
- The medication is new to the market.
- You haven’t taken the medication in years.
- The drug formulary for your plan has changed.
- The plan prefers you to use generic rather than brand-name versions.
- The proposed drug is unsuitable for the condition. For example, semaglutide (Ozempic) is a medication the Food and Drug Administration (FDA) has approved to treat type 2 diabetes. If you’ve been prescribed the medication for weight management, your insurance company may not cover it
How to request a special exemption
In cases when your insurance plan doesn’t cover a specific medication, you have options. You can:
Appeal the decision to deny coverage. Each insurer has an appeals process that they should list on their certificate of coverage, as well as the phone number and other contact information in case of an appeal.
During an appeal, you’ll most likely have to complete an appeals form, and a doctor will need to provide treatment information. Then, both an internal and external review process will take place. The process may take a couple of months.
You can also check with the medication’s manufacturer, as sometimes drugmakers offer discounts on their medications. You can check with them to see whether you can cut some costs on your prescription drugs.
If you need help covering the cost of medications, the free Optum Perks Discount Card could help you save up to 80% on prescription drugs. Follow the links on drug names for savings on that medication, or search for a specific drug here.
