Prescription insurance companies are not required to cover every medication available in the marketplace. In fact, most insurance companies have formularies, or lists of medications they do cover, and medications not on the formulary are not covered by their plan. Occasionally medications that are not on formulary may be approved if the insurance company receives an authorization letter sent from the doctor detailing why the doctor wants a patient to take a particular medication instead of other available options. Unfortunately there is no guarantee that the medication a patient needs for a particular condition will be covered, and the formulary is the list the insurance company uses to make these decisions.
About Insurance Formularies
Insurance company formularies can be tricky to navigate. Many companies have several levels, or tiers, in their formularies, which determine the level of insurance coverage or copay that will apply to a particular product. Medications listed in Tier 1 generally have the best insurance coverage, and generic medications commonly fall into this category. Tier 1 medications are often covered for the lowest copay a plan will offer. Drugs listed in Tier 2 often have less ideal insurance coverage than Tier 1, and Tier 2 medications are generally brand name products with no generic alternative. The copay for Tier 2 products will be higher than the copay for Tier 1 products, but lower than the copays for medications in higher tiers. Tier 3 is often reserved for non-preferred medications that are brand name, but have a preferred generic alternative available, and these products generally have a higher copay than products in Tier 1 and 2. Occasionally insurance companies will also have a higher level, Tier 4, for the most expensive, non-preferred products, resulting in the highest copays that can often reflect the entire out of pocket cost of the medication.
Navigating Insurance Formularies
While this is a general blueprint of insurance company formularies, each plan offers differing amounts of coverage for medications on their formulary. One insurance company may charge a $40 copay for medications in Tier 3, while another insurance company may charge $150 for the same product. Also, each insurance company’s formulary is developed internally, resulting in different formularies at each company. One company may have Crestor on Tier 3, while another may classify it as Tier 2.
Certain medications are commonly not covered by commercial insurance plans, either due to their cost or the thought that they may not be used for significant medical purposes. These include medications for cosmetic purposes, over the counter products and weight loss products. Prescription insurance plans vary greatly in the coverage they provide for medications, with some formularies being much more restrictive than others, therefore some companies may have a more extensive list of non-covered medications than others.
Medications that are excluded from coverage by Medicare plans include medications for weight loss or gain, cosmetic treatments, fertility products, medications to treat erectile dysfunction, medications to treat cold symptoms such as cough or runny nose, over the counter products, and prescription minerals and vitamins. Patients with a Medicare Part D plan who need to take these medications must figure out another way to pay for these products, without their insurance.
People with prescriptions for products that are not on their insurance company’s formulary may use the Prescription Discount Card from Discount Drug Network to lower their drug prices. The discount card can be used in place of insurance, and is accepted at over 65,000 pharmacies nationwide. This discount can reduce the cost of a prescription medication by up to 85%, depending on the medication strength and quantity needed as well as the pharmacy it is filled at.
The Price Finder tool can be used online to help the patient assess the costs of their medications at their local pharmacy before going to the store. Users can also check other pharmacies in their area to see if they offer lower costs for their medications with the Prescription Discount Card. This alternative to insurance can help decrease drug costs for those who are finding that changes in their insurance company’s formulary have altered the coverage of their medications, as well as those people whose new insurance plan does not cover their current medications.
Those interested in using the Prescription Discount Card to save money on prescription medications can sign up to receive the card in the mail or by email at discountdrugnetwork.com. The Price Finder tool can also be accessed through this website to discover which pharmacies offer the lowest cost medications in a particular area using the Prescription Discount Card.