Coverage and cost
Learn more about your pharmacy benefits, from filling a prescription to the difference between copays and coinsurance. Get answers to common questions below.
When paying full price or a percentage of the cost of your medicine, you may see changes in the amount you pay at the pharmacy. Drug pricing changes based on drug supply and demand, generics and alternatives becoming available, and changes in contracts with pharmacies. Because of these things, 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 medicine, you may want to check pricing at several participating pharmacies to determine where you may get the best price.
A network pharmacy is made up of pharmacies where your prescription plan is covered. Your health plan chooses a network pharmacy to provide you with convenient pharmacy services at better costs. Typically, a network pharmacy will include thousands of pharmacies across the country, both chain stores and independents. So even when you are traveling, you can find a pharmacy in your network.
When you need to fill a prescription, use one of the pharmacies in that network. When you use a pharmacy not in your plan's network, you may run into some inconveniences. For example, you will have to pay for 100 percent of the cost of your medication, up front. You will also have to submit a claim to your health plan to get reimbursed for that medication. Your health plan does not guarantee reimbursement for prescriptions filled at non-network pharmacies.
Finding a pharmacy in the network is easy. You can use the pharmacy finder feature on MyPrime. We will provide you with a list of pharmacies in your area. Visit our Pharmacy Finder, where you have the option to search for network pharmacies by zip code or pharmacy name.
Talk with your doctor. If you need a drug that requires a prior authorization, your doctor will fill out a prior 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 medicine alternatives.
Why do some prescription drugs need prior authorization? Who determines which drugs require prior authorization?
Generally, drugs that are prone to misuse or high cost require a prior authorization (PA). These medicines must meet certain criteria to ensure that the drug is used appropriately. Doctors and pharmacists at your health plan work with Prime Therapeutics to determine which require a prior authorization.
The amount paid for prescriptions by the member. If your drug benefit has different tiers, you may have separate copay amounts for each tier.
Coinsurance describes a way of cost sharing between you and your health plan. If you have pharmacy coinsurance, you will pay for a certain percent of your prescription drugs. For example, your health plan may have an 80/20 coinsurance plan. This means that you pay for 20 percent of your pharmacy costs, and your health plan pays for the remaining 80 percent. If a drug cost $100, and you have a 20 percent coinsurance, then you would pay $20 for that prescription.
With coinsurance, you save money by using drugs that are on your health plan's drug list, especially generic drugs. A drug list is a list of prescription drugs and supplies covered under your health insurance.
The benefit of coinsurance is that you can have a direct impact on the cost of your personal health care. On a coinsurance plan, the less your prescription drugs cost, the less you pay.
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 cost to you for a first-tier drug might be anywhere from $5 to $20. The second tier covers brand-name drugs on the drug list. The cost to you for a second-tier drug might be anywhere from $15 to $30 more than first tier generic drugs. 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.
A health savings account (HSA) is a tax-exempt savings account. You can put (or ask your employer to put) pre-tax dollars from your paycheck into an HSA. You can then pay for health care and prescription expenses from your HSA. HSAs are paired with high-deductible medical plans. You can use money in an HSA to pay for expenses such as doctor, dentist and chiropractor visits as well as prescriptions.
In some cases, you may not use all of the money invested in your HSA. In that situation, the money stays in your account for future use. If all of the money in the HSA is used during the year, you are responsible for the remainder of any deductible up to an out-of-pocket maximum for the year. At that point, the insurance plan is activated.
A formulary is a list of drugs covered by your health plan. The list is designed to provide you and your physician with the most safe, effective drugs at the most reasonable cost.
The drug list is developed by a Pharmacy and Therapeutics (P&T) committee. The P&T committee is made up of a diverse group of doctors and pharmacists. When adding or removing drugs from the drug list, the P&T committee reviews each drug for its safety, effectiveness, uniqueness and cost. This ensures that drugs on the drug list are safe for patients and effective in fighting disease. It can also include drugs that are unique in addressing certain health conditions.
Health plans use the drug list to provide their members with effective drug therapies at reasonable costs. For this reason, using drugs from a drug list is important for both you and your health plan.
Often, many drugs are available to treat the same condition. If two drugs are equivalent in effectiveness and safety, the drug list will include the lower cost drug. You're not required to purchase only drugs that appear on your health plan's drug list. However, you may pay more out-of-pocket for a drug that is not on the drug list. You may need to pay the full cost of the drug if it is not covered by your benefit plan.
Changes in a drug list result from decisions made at P&T committee meetings. The P&T committee meets quarterly to consider changes. These regular 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.
The process of adding and removing drugs from a drug list ensures that the drug list is kept current and that members receive the most appropriate drug therapies.
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 Prime monitors these reports, this may trigger a change in a drug list.
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.
Have you ever used an over-the-counter drug to treat a cold, upset stomach, headache or other condition? Over-the-counter drugs offer relief from some symptoms. The benefit of using an over-the-counter drug is convenience. You don't miss work or other activities to go to the doctor. Also, in most cases, over-the-counter drugs are less expensive than prescription drugs.
It's important to be informed about 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.
When taking over-the-counter drugs, be smart and be safe. Follow the directions on the box. Read all warnings. If your symptoms do not go away, see your doctor.
It's important that you follow the directions on your medication. When you look on a bottle of medication, you will see directions for use. You might read: "Take twice a day until medication is gone" or "take one pill with food for five days." These directions make the prescription most effective to treat your condition.
When you take your prescription drugs as directed, you should feel better faster, have less chance of a relapse of your condition and prevent your condition from getting worse. If you are taking a prescription medication and start to feel better before you finish your treatment, don't stop taking the medication. Even though you feel better, the medication may not have finished doing its job. If you stop taking your medication, the condition may come back or get worse. If you don't take all your medication as directed, you could put yourself at risk. You could make your condition worse or develop a new condition. Also, any condition that you don't effectively treat now could affect you later.
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.
The directions on prescription drugs are designed to help you get better. If you have questions about your prescription medication, talk with your doctor or pharmacist.
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 a middle-aged man would take that would not be appropriate for a teenage girl. 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 the pharmacist.
- 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 indications. (Indications are the reasons 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 what drugs are covered by your health plan. It checks for any drug interactions. It only takes a few seconds for the computer to check all of 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. He or she 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.
Ask your doctor or pharmacist if a lower cost drug option is available. To find out more about alternatives for a prescription drug, search by drug name under the Find Drugs tab. Then click on Similar Products. See if there are over-the-counter alternatives for your prescription drugs. In addition, ask your doctor or pharmacist to review all your current medications:
- You may no longer have a medical need for all your medications
- You may be able to take a lower dose of your medications
- You may be receiving similar medications unintentionally
Information in this Question and Answer does not substitute advice from your doctor.
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:
To find out if a generic equivalent is available for your prescription drug, search by drug name under the Find Medicines link. Another way to save is to use the PrimeMail home delivery pharmacy. Check your benefit plan for coverage.
In 2014, new pieces of the health care law took effect. This means you have a new way to get health insurance. The Marketplace is designed to help you compare and find health insurance plans that fit within your budget and meet your needs. Read more about the Health Insurance Marketplace at HealthCare.gov. You may also see it referred to as the Health Insurance Exchange.
Make sure you read about any plan you’re considering. Here are some things to keep in mind:
- Find out the full cost of a plan before signing up.
- See if your medicines are on the plan’s drug list, also called a formulary.
- Find out if you can get your long-term medicines through home delivery.
- Check to see if your medicines have special rules, such as having limits on the amount of medicine you can get at one time.
- See if your pharmacy is included in the plan’s pharmacy network.
Some plans may seem more expensive, but you'll want to look at more than just the premium, which is the amount you pay each month to be in the plan. You should consider the total cost of the plan and how it fits into your budget.
Here are a few things to think about when trying to figure out the total cost:
- Copay - the amount you pay for covered services, like doctor visits and prescription medicines.
- Annual deductible - the amount you pay out-of-pocket each plan year before your plan starts to pay.
- Annual out-of-pocket maximum - the most that you will have to pay out-of-pocket during the plan year. This usually includes copays and your deductible.
Usually, a plan will have different tiers, or levels of coverage for medicines. You may see plans with one to five tiers. Generally, the lower the tier, the lower the cost of the medicine. Here’s an example of how a plan might list medicines:
- Tier 1 drugs - the lowest-cost, mostly generic drugs.
- Tier 2 drugs - medium-cost drugs, most are generic and some brand-name drugs.
- Tier 3 drugs - high-cost drugs, mostly brand-name drugs.
- Tier 4 drugs - the highest-cost drugs, mostly brand-name, newer drugs.
- Tier 5 drugs - highest-cost drugs, can include specialty medicines.
As you shop for a health plan, check whether or not any medicine you’re taking now is on the plan’s drug list, or formulary, and see how much it will cost. Sometimes a plan with a higher deductible will have slightly lower medicine costs – so you may save money over the year. If your medicine isn’t on the drug list, ask your doctor about other medicines you could take instead, that are covered.
- PA stands for Prior Authorization. This means that your plan has to give authorization before it will help pay for certain medicines.
- ST stands for Step Therapy. Some medicines may require step therapy – meaning, 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. Some medicines have quantity limits, which means that the pharmacy may only be allowed to give you exactly enough medicine to cover a certain period of time. Quantity limits are usually for very expensive medicines (so you don’t buy more than you need), or for medicines that are more likely to be overused or abused.
You'll want to find a plan that works within your budget. When considering the total cost of your insurance, think about how your costs will add up over the year. Based on your own medical situation, you'll want to look at different things in each plan:
- Are you healthy? A plan with a lower premium may have a higher deductible, and higher copays for prescription drugs or doctor visits. Generally, people who choose plans with a higher deductible file fewer claims. But it's good to keep in mind that choosing a plan with higher deductible will also mean you'd pay a higher out-of-pocket cost, if you do file a claim. If you don't go to the doctor often or you don't take prescription medicines regularly, you could save money. A plan with a lower premium can save you money each month, but if you need medical help, you may pay more out-of-pocket.
- Do you expect to go to the doctor often? If you have a condition like high blood pressure or diabetes, you will probably visit your doctor a few times a year to track progress. You may want a plan with a higher premium and a lower deductible, as well as lower out-of-pocket expenses, like copays or coinsurance. That way, you'll pay less when you visit the doctor.
Yes. When you sign up for a plan, there will be a list of pharmacies that are in your network. These pharmacies are usually able to offer covered products and services at lower rates. You can check to see if your local pharmacy is on that list. If your pharmacy isn't on the list, or out-of-network, you will still be able to get your prescriptions filled there. But, medicines may cost you more since you are not using the network.
A member is someone who's covered by a health care or pharmacy plan. Some plans can have only one member (such as a Medicare Part D plan). Or, you can be a member of a plan, and if you have a family, anyone you bought coverage for is also a member. You may also see the word subscriber on some of the documents you review. A subscriber is the person who signed up for coverage.
When you visit your doctor, he or she may prescribe medicine for you. Here's how the plan works:
- Take your prescription and member ID card to the pharmacy to get your medicine.
- The pharmacist fills your prescription and checks with your pharmacy plan to see how much to charge you for your prescription.
- Because you have a pharmacy plan, you may pay less for your medicine - the amount you pay is called your cost-share. Your pharmacy plan pays the rest.
- Depending on how your health plan is designed, you may have to pay the full cost at the beginning of your plan year, until you meet your deductible. A deductible is the amount of money that you pay out-of-pocket for covered services, before your plan starts to pay.
A prescription drug plan, or pharmacy plan, is a part of your health care coverage. Prescription medicines 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 medicines 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 medicine to treat high blood pressure, or insulin to treat diabetes.
Prime supports pharmacy coverage by helping you:
- Order and refill your medicine.
- Choose generic medicines that may lower your costs.
- Get your long-term medicines through our PrimeMail home delivery option.
Your pharmacy plan covers many different kinds of prescriptions medicines. You can see the exact medicines your plan covers by reading the drug list, or formulary. Your plan’s drug list will tell you what medicines are covered and which are not, including brand-name and generic medicines.
Keep in mind that some medicines may be on your drug list, but they may not be covered for situations that aren't considered medically necessary. For instance, the medicine Retin-A (tretinoin) treats acne in people under age 21, but a doctor may prescribe it for cosmetic purposes. Check your plans’ Evidence of Coverage or Certificate of coverage document to learn more.
It depends on the plan you choose. When you're looking for a plan, check to see what is included for the price you pay.
- Some plans have a higher premium, but your deductible may be lower and your plan may pay more of your medical or prescription drug costs.
- Other plans might have a lower premium, but you may have a higher deductible and pay more for your prescription drugs or doctors' visits.
Why is the pharmacy benefit important?
1) Meet Joe
Joe is a healthy guy. He hardly ever gets sick, so he doesn’t go to the doctor often. Joe's active and likes to ride his bike. One day last spring, Joe hit a pothole and crashed. After visiting the hospital and getting x-rays, Joe learned he broke his arm, and needed surgery to fix it.
After surgery, Joe's doctor prescribed a medicine to help manage the pain, along with an antibiotic. Joe's prescription drug plan helped save him money:
|Joe's pain medicine*||Total cost||$200|
|Joe's 25% copay||$50|
|Joe's plan paid||$150|
|Joe's antibiotic*||Total cost||$300|
|Joe's 25% copay||$75|
|Joe's plan paid||$225|
|Total saved on both medicines||$375|
2) Meet Steve
Because Joe's prescription drug plan paid for most of the cost of his pain and antibiotic medicines, Joe saved almost $400 on the cost of those two drugs. Joe's prescription drug plan paid for most of the cost of his pain and antibiotic medicines, Joe saved almost $400 on the cost of those two drugs.
Steve just learned he has diabetes. He's talked with his doctor, and treatment is going well. He's exercising more and watching what he eats. He's already slimmed down.
To control his condition, Steve has to take medicine every day and check his blood sugar regularly. Thanks to Steve's pharmacy coverage plan, he’s able to get the medicine he needs to stay well. Because Joe's prescription drug plan paid for most of the cost of his pain and antibiotic medicines, Joe saved almost $400 on the cost of those two drugs. Joe's prescription drug plan paid for most of the cost of his pain and antibiotic medicines, Joe saved almost $400 on the cost of those two drugs.
|Steve's diabetes medicine*||Per month||$100||Cost per year||$1,200|
|Steve's 25% copay||$25||Yearly copay||$300|
|Steve's plan paid||$75||Yearly plan payment||$900|
|Steve saved||$75||Yearly savings||$900|
Steve could choose to fill the prescription for his diabetes medicine through his plan’s home delivery pharmacy option. Not only can he get a 3-month supply of his medicine mailed straight to his house, he can even get a discount:
|Steve's diabetes medicine*||3-month supply||$250||Cost per year||$1,000|
|Steve's 25% copay||$62.50||Yearly copay||$250|
|Steve's plan paid||$187.50||Yearly plan payment||$750|
|Steve saved||$187.50||Yearly savings||$750|
*Numbers used here are for illustration only – your actual drug costs might be different, based on the drugs you are prescribed and your plan design.
- The pharmacist uses the number on your ID card to check the details of your plan. This way, the pharmacy can check to see if your plan covers the drug you were prescribed, based on your plan's formulary, or drug list.
- They learn what your copay or cost share amount will be. This is the amount of money that you pay out-of-pocket for your prescription medicine.
- If your prescription is for a brand-name drug, they find out if you could save money by using generic drugs instead of brand-name drugs. A generic drug has the same active ingredients as a brand-name drug, and is put on the market when the patent for the brand-name drug runs out. Using generic drugs can save you money.
Prime Therapeutics Specialty Pharmacy services provide specialty medicines that treat long-term, complex or life-threatening conditions (like multiple sclerosis, cancer, hepatitis C or rheumatoid arthritis). These medicines have special shipping and handling requirements. And, they usually need to be taken at specific times and in a specific way.
That's why Prime offers Prime Therapeutics Specialty Pharmacy services. If your doctor prescribes a specialty medicine for you, Prime Specialty Pharmacy services is there to help.
Prime Specialty Pharmacy services go beyond a traditional pharmacy.
We'll help you take care of your condition with:
- Confidential support from a dedicated care team
- A nurse or pharmacist available to you by phone, 24 hours a day, 7 days a week, 365 days a year
- Personalized answers to questions about your medicines and potential side effects
- Educational materials about your condition
Your care team will work with your health care plan to help you get your medicines covered. We can also help you get financial help if you qualify.
Your pharmacy plan works with pharmacies all across the country to create a network. A network is a large group of pharmacies that have contracts with an insurance plan to offer covered products and services at a lower rate to insurance plan members.
- Pharmacy networks are usually very large and include major chain pharmacies as well as local independent pharmacies.
- You can also use an out-of-network pharmacy, but your plan might not pay for your prescriptions. This means your medicine may cost you more. In some cases, your plan might pay for part of your prescription, but you would have to file a claim for reimbursement.
Home delivery pharmacy is an option if you take long-term medicines for conditions like high blood pressure, asthma or diabetes. Using home delivery pharmacy, you can get up to a three-month supply of your medicine delivered right to your home. Home delivery pharmacies can save you time and money. Check the details of your plan to find out more about home delivery pharmacy. Some plans require you to get your long-term medicines through home delivery pharmacy in order to have some of the cost covered. A home delivery pharmacy is also called a mail order pharmacy.
When a Prior Authorization is needed, it means your prescription drug plan must approve your prescription before PrimeMail can fill your order. Step Therapy means you take a "step" approach with your medicines. 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 medicines must be tried without success before other medicines will be approved. PrimeMail will work with your doctor to validate what drugs have been tried.
For both Prior Authorizations and Step Therapy, PrimeMail will work closely with your doctor to determine if your claim will be authorized. This process may take up to five to ten business days. Once approval is received, PrimeMail will ship your medicine. If we are unable to get an approval from your prescription drug plan, PrimeMail will notify you about the denial.
Prescriptions can be profiled at the request of the member. You could choose this option if you still have medicine on hand and do not require any more until a later date. When you are ready to get the prescription filled, call Member Services at 877.357.7463 or view your medicines to start your order.