Health Insurance and Prescription Drug Coverage

To millions of Americans, it’s just a fact of life to take prescription medication. In fact, the average American spends well over $1,000 per year on prescription drug costs—and that is the cost of this plan even with health insurance. a stack of flyers on a table

You have to pay for your prescriptions like you would have to pay for any other product or service, and it’s easy to see these costs mount if you take several medications at once. To most people, paying out of pocket for the full cost of most drugs would be financially devastating, which is why anyone who has health insurance often wants to use it to help supplement these costs.

Yes, most of today’s health insurance plans will cover prescription drug costs. However, they are not guaranteed to cover 100% of costs, leaving you to pay nothing. Therefore, you must examine your policy to determine the precise benefits your plan will provide.

The Necessity of Prescription Drug Insurance

Without health insurance coverage to cover most of the cost of your drugs, you might face hundreds or thousands of dollars in out-of-pocket expenses that you cannot afford.

Fortunately, due to changes in U.S. health insurance laws, nearly all medical plans sold today will include prescription drug coverage. However, certain conditions to coverage will exist. For example:

Some plans won’t cover prescription costs, and you must check with your insurer to verify coverage if this is the case.
No plan will cover every drug on the market, and policyholders will need to choose a drug from the insurer’s formulary in order to receive coverage. Most plans cover multiple drugs to treat a single condition.
Though having coverage will significantly reduce the policyholder’s out-of-pocket cost for medications, the policyholder will still have to pay a share of the cost themselves.

Understanding Costs Under Prescription Drug Coverage

It’s important to review the medication that your doctor recommends, to see if your insurance plan will cover it. If you find that your plan does not cover a particular drug, however, then you might be able to choose an alternative medication from within the prescription formulary. Additionally, if you must take a specific drug, then there is an appeals process to help get insurers to cover the cost.

To determine costs of a particular drug, most insurers divide medications into tiers. Those in lower tiers are often generic or commonplace drugs that work for most consumers. Higher tiers will usually include specialty and brand-name drugs, many of which can be substituted for lower-tiered generics. Therefore, higher-tier drugs are more likely to cost you more money.

The best way to ensure that you get the prescription you need at a price you can afford is to talk to your doctor and your insurer. They can help you determine the precise cost of each prescription.

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