A Trip to the Doctor’s Office …

It’s Monday morning and you’ve taken a couple hours off work to go to the doctor. You’ve been experiencing a few uncomfortable symptoms and, naturally, would like them to go away. After performing an exam, your doctor is pretty certain your condition will be improved with a full cycle of a medication we’ll call Zanzaflan®. He writes you a prescription, gives you a lollipop, and sends you on your way.

For most people, the next step is to drive to the pharmacy and get the prescription filled. But most people don’t know about an intermediate step that can save a lot of potential hassle: to check and see if Zanzaflan is covered under your health plan — or not.

“A lot of Highmark members know they have different levels of coverage when it comes to medical services, but they don’t realize that’s the case for prescriptions, too,” says Steven Capuzzi, a pharmacy sales consultant at Highmark Inc. Just as your insurance company will pay all or part of the costs for the medical care you receive, your health plan will cover all or part of the cost of most of the medications your doctor prescribes so that you don’t have to pay full price for the medication. But it’s good to know that medications fall under three different categories of coverage, as Steven explains.

“With prescription coverage, the first possibility is that a medication is in your formulary (the list of medications Highmark covers) and covered automatically by your plan. Second, it may be in your formulary, but covered only if prior authorization (also known as preauthorization) criteria are provided by your doctor. If it’s not in your formulary at all and therefore not covered, it’s also possible for your doctor to submit a request to have it covered as a non-formulary exception.”

Check Your Prescription Coverage Before You Head to the Pharmacy

Capuzzi notes that Highmark members can check their prescription coverage online by logging in to their member website. (Right now, this information is easiest to get to if you use a laptop or desktop computer and access the full site.)

Knowing what your prescription benefits are before going to the pharmacy can save you from making a trip and waiting in line only to find out from the pharmacist that your insurance doesn’t cover a specific drug, and being asked if you’ll be paying out of pocket.

Remember, as wonderful as your doctors may be, they might sometimes write prescriptions for drugs they don’t realize aren’t covered by your plan. Doctors accept many different kinds of plans from patients, all with different formularies, and it would be challenging — if not impossible — to keep track of all of their patients’ prescription plans. As patients, it’s probably not fair for us to expect them to be able to do that.

However, by talking with your doctor and working with your insurer, there are usually ways to get the drug treatment you need without having to pay full price for a specific brand-name medication.

Prescription pad and pills

Prescription Coverage: Know All Your Options

If you check your formulary and find out that the medication your doctor prescribed is covered, you’re good to go. You can go get that prescription filled and head down the road to recovery.

But what happens if your doctor prescribes Zanzaflan and it’s not covered outright by your Highmark health plan? Well, the smart next step is to ask your doctor if she can prescribe an alternate medication that is covered. The alternate could be a generic, or it could be a similar brand-name drug. But if your doctor believes you need the exact medication she prescribed, and no alternate will do, she’ll need to contact Highmark and explain the situation for coverage to be considered. Otherwise, you will have to pay out of pocket for the Zanzaflan.

Let’s say your doctor does go ahead and contact Highmark (because paying full price, out of pocket, should really be your last resort). What happens next?

  1. If Zanzaflan isn’t covered outright, it may be covered under “prior authorization requirements.” As Capuzzi clarifies, medications requiring prior authorization will be covered by your insurance company only if certain criteria have been met (for instance, if your doctor has already prescribed alternate on-the-formulary medication and seen no improvement).
  2. Then, in order to obtain coverage for the medication in question, your doctor will need to submit a request along with supporting medical documentation.
  3. Once that is approved and it is determined that Zanzaflan meets the prior authorization criteria, you’ll proceed as usual, picking up your medication from the pharmacy. In most cases, your pharmacist will notify you that your prescription has been authorized.

Even if a drug isn’t covered outright or under a prior authorization requirement, there is still a chance that Highmark will cover some of its cost. For this to happen, your doctor must prove that a drug that isn’t on your formulary is actually medically necessary for your treatment, and that no other drug will suffice.

So there you have it. If the (by the way, fictional) drug Zanzaflan isn’t covered by your health plan, chances are something comparable will be. If not, your doctor and your insurance company may be able to work something out so that you don’t have to pay the full price of your prescribed medication.

In any case, you can save yourself a lot of hassle by checking out your prescription coverage before you go to the doctor’s office or pharmacy.

Frequently Asked Questions: Answers From Our Pharmacy Expert

Why do prescriptions have to be so complicated?

With the rising cost of health care, insurers like Highmark have worked hard to help protect their members from the full effects of price increases. In order to do that, we collaborate with different pharmacies and companies to decrease the cost of medications.

While effective, this method does leave some drugs uncovered, or covered only under prior authorization, so always be sure to check if a medication your doctor prescribes is covered under your plan before you pick it up at the pharmacy.

What’s the deal with generic medications?

Under U.S. patent law, when a pharmaceutical company develops a drug and secures a patent for it, it is theirs (and only theirs) to sell for a set number of years. After that time, other companies are free to use and sell the combination of active ingredients in the drug that make it effective. It is at this time that companies market generic medications. These include the exact same combination of active ingredients as their brand-name counterparts, at a fraction of the price.

In many states, like West Virginia and Pennsylvania, your pharmacist is required by law to replace a brand-name prescription order with a generic order, if one is available. In some other states, like Delaware, pharmacists are able to substitute generic medications if certain conditions are met, but they are not required to do so. In either case, it’s a good idea to ask your doctor to write the prescription for the generic version anyway. Generics are more often covered by insurers’ prescription plans than brand-name drugs are, and are usually available at a lower copayment.

Note: While generics are usually the least expensive option available, some generic medications have radically increased in price over the last decade. The antibiotic doxycycline, for instance, has skyrocketed in price, and can now cost 5,500 percent more than it did 10 years ago. Be on alert for expensive generic medications, and ask your doctor if there is an alternative to expensive generics. Learn more about the rising costs of some generic medications with this generic drug fact sheet created by the Highmark pharmacy team.

I have a regularly prescribed medication. Do I have to go to the pharmacy every month?

No. If you’re taking any kind of “maintenance” medicine, or a medication with a standing prescription from your doctor, you may be able to take advantage of mail-order pharmacy services.

Highmark, for instance, partners with a company called Express Scripts, which delivers medications right to our members’ doors with free standard shipping. For these types of medications, mail-order pharmacy services can save you time and money, and you may also be able to receive a convenient 90-day supply of your medication at once, with a three-month prescription from your doctor.

What’s this I’ve been hearing about pharmacy networks?

Just like you have a group of hospitals and other health care providers that are considered “in-network” with your health insurance provider, you likely also have a network of pharmacies that your insurance company has developed agreements with in order to deliver certain medications at a lower cost. Your pharmacy network is likely specific to your health plan, so be sure to check with your health insurance provider to find out what pharmacies are in-network.