How to See if Your Healthcare Plan Covers Your Prescriptions

There are many reasons why you’d want to look out if your insurance plan covers your medication prescription. If you’re looking around for a new insurance plan and it’s important to find out if your current medications are covered.

Maybe your healthcare professional just prescribed an alternative medication and you would like to see it before you choose the insurance policy. While this information is searchable, it does require some skill to find it. We will help you through this article.

Whenever doctors prescribe an expensive form of medication, the first thought in your mind is if your insurance plan covers the cost. Or even you would like to understand what tier a drug is in, or whether it is a preferred or non-preferred brand.

You have different options for getting this information. We’ll assist you in understanding where to look for it.


Does my new insurance plan cover my prescription?

Follow the following steps to figure out the prescriptions covered under your new Marketplace plan:

  1. Visit your insurer’s website to review an inventory of prescriptions your plan covers
  2. See your Summary of advantages and Coverage, which you’ll get directly from your insurance firm, or by employing a link that appears within the detailed description of your plan in your Marketplace account.
  3. Call your insurer to inquire what’s covered. Have your plan information available. It all available on your insurance card, the insurer’s website, or the detailed plan description in your Marketplace account.
  4. Check out any details your insurance firm sent you for the coverage you have got


Summary of Benefits and Coverage (SBC):

This document may be a summary of what the health plan covers. While the formulary doesn’t actually tell you ways much different tiered drugs will cost you, the SBC will outline what quantity your copay is for every tier.

When you’re buying healthcare plans or determining whether to stick or to not stick with your current one, use the formulary and SBC to search out whether a selected medication is covered. Based on an example of a tier 3 medication such as insulin SBC, is to be considered a “non-preferred brand”, meaning that you simply need to pay 40% of the drug’s cost. When choosing a health plan option, it’s important to get one with a cheap premium provider (the amount you buy insurance every month) and also consider which plan has the simplest coverage and possibly the lowest out-of-pocket expenses for your medical needs.

During open enrollment periods (the time people are buying new plans, insurance companies are required to form list of medicines and SBCs available. It’s your right to request a list of medicines for an idea you’re buying.


Can I attend my regular pharmacy to urge my medication?

Just like different health plans cover different medications, different health plans allow you to buy your medications from different pharmacies (called “in-network pharmacies”). Call your insurance firm or visit their website to seek out whether your regular pharmacy is in-network under your new plan and, if not, what pharmacies in your area are in-network. You’ll also learn if you’ll get your prescription delivered within the mail.

If you’ve got additional questions, call 800.858.1772 to get the required information.


Drug Coverage Changes With Continued Spending Hike

Spending on prescription drugs rose by 5.2 percent in 2015 and is projected to continue to climb, much faster than overall health spending, in the coming years.

The increase is largely attributed to the high cost of specialty medications used to treat conditions such as rheumatoid arthritis and cancer. And greater medication use overall due to millions of Americans gaining access to insurance coverage through the Affordable Care Act also contributed to the surge in spending.

Related Post: ClaimLinx Prescription Drug Card Services

As it stands though the rise of powerful, expensive prescription drugs has become the greatest drain on American pocketbooks. Spending on specialty medications rose 18 percent last year, while spending on standard drugs rose less than one percent, according to a report by the largest prescription benefit manager in the U.S., Express Scripts Holding Co.

The report also found the average price of brand-name drugs on the market increased by 16.2 percent in 2015 and has jumped 98.2 percent since 2011. One-third of brand-name prescription drugs had price increases exceeding 20 percent last year.

Still, this year’s increase is half the rate in 2014, which spiked to 12.6 percent, the largest price jump since 2003.

What was different in 2015 is that the overall boost in costs was moderated by more restrictions from pharmacy benefit managers and insurers. These companies exerted more control over the drugs their costumers could get access to, as they were more willing to refuse coverage of expensive medications than in the past.

Related Post: Senate digs into why drug prices are so high

This trend will likely continue as drug prices continue to rise in the coming years, forcing many customers to become more flexible with accepting generic drugs over their name-brand counterparts.

Cumulatively from 2013 to 2018, prescription drug spending is expected to rise by an average of 7.3 percent annually, according to a report from the Department of Health and Human Services.

This is down from the spike observed in 2014 but is still higher than before 2013, when the country observed unusually slow growth — spending rose about 2 percent between 2008 and 2012.

For this reason, drug spending will continue to be a growing concern for clinicians, insurers and customers alike.

ClaimLinx Prescription Drug Card Services

What many people do not know is that there are various ways to cut the cost of those expensive prescriptions that can sometimes cut into their budget. The 2 most common ways to save members money is to 1) research the particular medication the member is taking and the frequency (dosage and how many times a day/week/month the medication being used), and explore opportunities to save money, such as the use of a drug savings copay card 2) obtain additional information from the member to see if they may qualify for the manufacturer’s pharmaceutical financial assistance programs that are available (usually eligibility is based on gross household income for these programs).

Related Post: Use The ClaimLinx Prescription Savings Card

For example, if a member is prescribed Lipitor from their physician, there is a savings card called the LIPITOR Choice Card. This card is not insurance, but can be used at many participating pharmacies and can be financially beneficial to the Employer as well as the employee.  Here’s how it works:

-You will pay $4 for a 30-day supply (30 tablets) if: you use commercial/private insurance and your out-of-pocket expense for a 30-day supply of name-brand LIPITOR is $130 or less.

-You will pay $30 for a 30-day supply (30 tablets) if: you do not use prescription health coverage to purchase your name-brand LIPITOR under this program or you use commercial/private insurance and your out-of-pocket expense for a 30-day supply of name-brand LIPITOR is $130 or more.

For all eligible patients, you can qualify for up to $2500 of savings per calendar year. After a maximum of $2500, you will pay usual monthly out-of-pocket costs or the primary insurance deductible will have already been met and would then be covered under your primary insurance.

Related Post: Drug Coverage Changes With Continued Spending Hike

Another example would be the medication Humira. This is a very costly medication to both the employer and the member, and the typical price is @ $3,000.00. However, with the manufacturer coupon the cost to the member can be as little as $5.00 when they pick up their prescription at the pharmacy.

Please have the member contact Suzanne Garcia for assistance. She will need the name and dosage of the medication and a general idea of the household income.

ClaimLinx is proactively working to save our clients and members money and can provide cost-savings prescription drug programs and solutions. Contact us for more information.

Excessive Drug Costs Could Cause Price Caps

Gilead Sciences’ drug, Sovaldi, which treats hepatitis C, is currently on the market for $1,000 per pill. The high cost raises questions on whether government should regulate the cost of the life-saving drug and others of it’s kind, according to an article in Modern Healthcare.

Sovaldi has proven to be a very effective treatment, with a cure rate of more than 80%. The problem is the cost to insurers and patients: a 12-week treatment costs $84,000.

Related Post: Excessive Drug Costs Could Cause Price Caps

Karen Ignagni, president and CEO of America’s Health Insurance Plans, agrees something needs to be done.

“We need to sit together to begin talking about how we can attack this problem together before the government has to. We cannot sustain six-figure therapies and we’re at the beginning of that trend,” she said in the article.

Representatives of the pharmaceutical industry are quick to point out the high costs of developing these life-saving drugs. John Castellani, president and CEO of Pharmaceutical Research and Manufacturers of America, feels the FDA approval process needs updating.

“It costs on average $1.2 billion, and takes 10 to 12 years to get a drug to market. We have to modernize the discovery process. We can only be as innovative as our regulator,” said Castellani.

Ignagni, however, believes pharmaceutical companies should decrease pricing to avoid governmental intervention.

Related Post: Costs Spike As Pharma Companies Reprice Old Drugs

“Manufacturers are charging whatever they can get away with,” Ignagni said. “We can’t have a system that operates that way. We can’t sustain it. Talking about price is often akin to calling fire in a crowded room. No one wants to do it until they have to,” she said.

Please read the Entire Article by Paul Demko here.

ClaimLinx specializes in consulting individuals and businesses on ways to save money on prescriptions. Depending on the dose and drug, we can find a program that may reduce your costs by as much as 50%. Did you know there are many patient assistance programs that go unused every year because people don’t know about them? Employers and individuals can benefit from taking advantage of these programs saving both the company and employees thousands of dollars in medical costs.  Many programs are available online with coupons or filling out a simple form.  We can navigate you through the process to get the maximum benefit cost savings.  Contact us today if you think you are paying too much for prescriptions.