WPS Health Insurance Blog

Is my medication covered?

Posted by Ryan Kanable

Jan 2, 2014 9:04:00 AM

vials of pillsYou may have had a prescription for a drug to help you recover from an injury. You may rely on a prescription drug for a health condition. You could even have several prescriptions to help you manage a chronic condition. The question is, how do you know if your prescription drugs are covered by your health plan … and at what cost to you?

Most health insurance companies cover the same categories of drugs to treat blood pressure, infections, pain, and other ailments. However, the specific drugs within each category vary by health insurance company. That means you need to check your health plan’s formulary. A formulary is a list of medications preferred by your health plan that your doctor can refer to when you need a prescription. It includes generic and brand-name prescription drugs. Drugs that are unproven, experimental, or offer no advantages over currently available drugs generally don’t make the list.

Most formularies group drugs into different categories, or tiers. Below is a grid representing a typical three-tier benefit commonly offered by health plans. There are financial incentives, such as lower cost sharing (copay and/or coinsurance) for lower-tier medications. Lower-tier drugs are usually generic and brand-name medications that are on the formulary; these are also known as “preferred” drugs.

Prescription drug tiers

 Tier 1

 Generic drugs

 Low cost sharing

 Tier 2

 Preferred brand-name drugs

 Higher cost sharing

 Tier 3

 All other drugs (nonpreferred)

 Highest cost sharing

If your doctor decides to prescribe a medication for you, it’s a good idea to make sure he or she selects an appropriate drug from your formulary. If you are prescribed a drug that’s not on your formulary, you may have to cover a larger percentage of the cost—or even the entire cost—of the medication yourself.

If you have a WPS health plan, you can view a lot of helpful pharmacy information online. You can take a look at the WPS formulary and find out which drugs require preauthorization. Also, regardless of what health plan you have, you can check out ways to lower your prescription drug costs, read about reducing medication costs, and more. We’re here for you to help you understand your benefits better!

Topics: health insurance