Like anything in the medical sector, prescription drugs are costly without insurance. Prescription drug plans ease the costs and must do so in compliance with state and federal regulations. Prescription drug coverage is one of the most systematic and organized types of coverage.
As per state and federal regulations, all prescription drug policies must cover medications in each U.S. Pharmacopeia category and class, with the same number of drugs in every category.
Every drug plan has its own list of medications known as a formulary. Formularies divide medications into tiers, categorizing drugs based on whether they’re preferred or non-preferred, generic or brand name, or specialty drug. Lower tiers are less expensive, while higher tiers are the most costly.
When paying for a medication:
In 2023, all plans aside from Medicare Part D and grandfathered plans have an annual out-of-pocket maximum for individuals and families. In 2023, individuals will not have to pay more than $9,100 per year on medications, and families won’t have to pay more than $18,200 in yearly out-of-pocket costs for their medications.
Insuring medications isn’t always a one-step process. For example, your doctor may want you to take a certain drug, but your insurer may require you to take a generic or less expensive version of that medication for a period of time before providing coverage for a more expensive drug.
Prior authorization may also be required, where your medical provider must submit the prescription to the insurer before your insurer approves coverage for your medication.
Many health insurance plans, including Affordable Care Act (ACA) Health Insurance Marketplace Plans, already have prescription drug coverage built-in. However, some individuals may have to enroll in separate prescription drug policies. For example, individuals enrolled in Original Medicare (Part A and Part B) or certain Medicare Advantage Plans have to enroll in Medicare Part D (Medicare’s prescription drug coverage) separately.
If you’re enrolling in a new prescription drug plan, make sure your prescriptions are included in the plan’s formulary. You can visit the insurer’s website or call them directly.
At The Health Insurance Value, we provide guidance to ensure that you won’t pay more for your medications than you should. Your needs are our top priority, and today, you can find the policy that gives you the coverage you deserve at a price you can afford.
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