WPS Health Insurance Blog

Are my prescription drugs covered?

Posted by Alexandra Radel

Dec 18, 2014 8:45:00 AM

prescription drugsWhen I received my new health insurance I didn’t know what prescription drugs were covered by my health plan. With a little searching and a phone call, I had all the information I needed. Do you know if your prescription drugs are covered by your health plan … and at what cost to you?

Follow these tips to help you discover what drugs are covered under your health plan.

  • Visit your insurer’s website to review your health plan’s formulary, also known as a preferred drug list. 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.
  • Call your insurer directly to find out what drugs are covered. Be sure to have your plan information available before you call.
  • Review your benefit and coverage materials that were mailed to you.

How does the formulary impact the cost of my drug?

Most drug benefits 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 (non-preferred)

 Highest cost sharing

What if my prescription isn’t on my formulary?

If your prescription is for a class of drug eligible for coverage under your plan, you will pay a higher cost sharing for your drug. For example, health plans cover drugs to treat high blood pressure, but not all high blood pressure drugs are “formulary”. As indicated in the grid above, non-preferred/non-formulary drugs are generally a higher cost to you.

If you want to find a lower cost drug for your condition, ask your doctor to prescribe a similar drug that is formulary. You can provide the formulary to your doctor or direct him or her to the appropriate website.

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. Regardless of which health plan you may have, you can visit our Health Center for tips on lowering your prescription drug costs, managing drug side effects, and more.

Topics: Individuals & Families