Prescription Coverage

Prescription coverage varies between different insurance companies and policies. Most policies will cover a portion of certain prescription drugs, but it is up to you to know which drugs your policy covers and how much of the price is covered.

The cost of prescription drugs has increased a tremendous amount over the past years. In fact, prescription drug expenses are increasing faster than any other area of health care. While prescription medication can be a wonderful miracle that improves and even saves lives, the chance to experience a miracle is not cheap.

Prescription coverage is dependent on a few factors. A prescription written by a physician is necessary. Some insurance plans require that only certain pre-approved physicians can give you a prescription. This prescription is then taken to a pharmacy to be filled. Again, some insurance plans require that the prescription be taken to an affiliated pharmacy of you want to have the full coverage that is offered.

Generic vs. Brand Name
A major factor in prescription coverage is the difference between generic drugs and brand-name drugs. Many brand-name drugs have an FDA-approved generic version that is comparable. Ask your doctor about the difference between a brand-name drug that you are going to take and the generic drug, if there is one.

Most policies will pay for a portion of a generic medication and an even smaller portion of a brand-name medication, which means that you will pay for a portion of your medication. Insurance companies have lower prescription coverage on brand-name medication because the brand name is a more expensive drug that the generic. Just like in a department store or grocery store when you pay more for brand-name clothes and food, your brand-name drugs cost everyone more, including you. This means that you will pay a higher co-pay for a brand-name drug than a generic drug.

For example, one particular insurance company charges its policyholders $40 for brand-name medication and $20 for generic medication. That's a 50% difference! Talk to your doctor about prescribing the generic version of your medication if you prefer to pay less, which is the case for most insurance policies.

Some insurance providers require that you receive the generic version if it is available. If you prefer not to do this, you may find yourself paying for your entire medication without any prescription coverage at all. Or you may have to be required to pay the generic co-pay plus the difference between the cost of the generic drug and the brand-name drug. Be sure to check with your own insurance policy if you are unsure about your generic vs. brand-name restrictions.

Prescription Coverage Limitations
There are several limitations that most insurance policies have in which your prescription coverage is void. The following factors depend on your personal policy, so be sure to check with your provider if you have any questions about prescription coverage limitations.

• Over-the-counter drugs (also known as OTC) rarely have prescription coverage, unless this has been specified in your personal insurance policy.
  
• Drug products that are used for cosmetic purposes are usually not covered. Insurance policies usually only cover medical issues and cosmetic issues do not qualify.
  
• Drugs that are not approved by the FDA or on the insurance company's approved list of drugs have no prescription coverage. This includes experimental drugs.
  
• If medication is lost or stolen, it is usually does not have prescription coverage for replacement medication.
  
• Some drugs require prior authorization from your insurance company before you are able to receive a prescription for it. Your physician may need to apply in advance for the prescription or may need to contact your insurance company to receive authorization at the time of prescribing. Without this authorization, prescription coverage is void.