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Ever Wonder Which Medications Your Insurance Covers

Colleen MoroneyWhen you receive a prescription from your doctor, you may be uncertain how much of the cost will be covered by your insurance. You may wonder, “Can I afford this medication?” Sometimes the answer to this question may be hard to find. Understanding the insurance company terms can help you as you fill your prescriptions for your medications. Here are some common questions and answers to keep in mind:

What does it mean if my prescribed medication is “non-formulary?”

If a medication is “non-formulary,” it means it is not included on the insurance company’s “formulary” or list of covered medications. A medication may not be on the formulary because there is an alternative proven to be just as effective and safe, but is less costly. If you and your doctor believe that the non-formulary medication is necessary, you will need to request that your insurance make an exception based on your case, or you will need to pay the full cost yourself or “out-of-pocket”. If you have Medicare, it is your right to file an appeal and get a decision that is unique to your situation. For information about your insurance plan’s formulary and your appeal rights, it is best to contact your insurance company. Your Member Services phone number is usually listed on the back of your insurance card.

What does it mean if my medication requires a “prior authorization?”

A “prior authorization,” sometimes referred to as a “prior auth” or abbreviated as “PA,” is a procedure whereby your doctor provides your insurance company with an explanation of why you need a specific treatment for it to be covered under your plan. Insurance companies may use prior authorizations to make sure that medication use is appropriate and safe.  Ultimately, the final decision to approve or deny a prior authorization is made by the insurance company’s team of expert pharmacists and doctors who have reviewed both your case and the scientific evidence on the medication. If you need more information about a prior authorization, it is best to contact your insurance company because they will have the most current information on the status of your claim.

What is a “deductible?”

Some insurance plans have a “deductible,” which is a certain amount of money you must pay out-of-pocket before your insurance begins to pay for all or part of your medications and other medical services. For example, if your plan has a $500 deductible, you will have to pay $500 out-of-pocket for your medications and medical care before your coverage takes effect. If you are discharged from the hospital with new medications and you have a high deductible plan, it may be good idea to call ahead to your local pharmacy to make sure you will be able to get your prescriptions promptly and at a cost you can afford.

What if I cannot afford the medication I am discharged on?

It is very important to take the medications your doctor prescribed to stay healthy and avoid future hospitalizations. If you feel that your medication is too expensive, you can ask your pharmacist if there is a lower-cost alternative. You will also want to discuss your options with your doctor to find the most affordable and effective option for you. Your healthcare team wants to help you get the best care possible, and that also means making sure you get care you can afford.

Want to know more about prescription formularies? See some of the helpful links below:

By Colleen Moroney, 2015 Pharm.D. candidate, University of Pittsburgh School of Pharmacy, and Sue Skledar, R.Ph., MPH, FASHP, clinical specialist, University of Pittsburgh Medical Center Health System Formulary Management and Drug Use Policy and associate professor, University of Pittsburgh School of Pharmacy