Jeffrey Wade
There are several ways to find out if you have prescription insurance. One way is to call the number on the back of your insurance card. Another option is to visit your insurer's website to review a list of prescriptions your plan covers. You can also check your Summary of Benefits and Coverage, which you can get directly from your insurance company or by using a link in the detailed description of your plan in your Marketplace account. If you're already at the pharmacy, you can ask the pharmacist whether the prescription is covered by your insurance. Most insurance companies also have portals and mobile apps that can help you price a drug based on your current insurance plan coverage benefits.
| Characteristics | Values |
|---|---|
| Finding out if a health insurance plan covers a prescription | Call the number on the insurance card |
| Visit insurer's website | |
| Use a prescription look-up tool on HealthCare.gov | |
| Use insurer's mobile app | |
| Ask the pharmacist | |
| Check with the doctor | |
| Review Summary of Benefits and Coverage | |
| Check the formulary | |
| Check the drug tier | |
| Check if the drug is a preferred brand | |
| Check if the drug needs prior authorization | |
| Check if the drug is medically necessary |
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What You'll Learn
Check your insurer's website or app for a list of covered prescriptions
When you need a prescription drug, one of your first thoughts may be how much it will cost you. It is important to know whether your health insurance plan covers a certain prescription, especially if you are shopping around for a new plan or have been prescribed a new medication.
Most insurance companies have websites and mobile apps that allow you to check a list of covered prescriptions and price a drug based on your current insurance plan coverage benefits. You can log in to your insurer's website or app using your member ID to access this information. You will need to know the name of the drug and the prescribed dosage. Once logged in, look for the 'Prescription' or 'My Coverage' section, and then select 'Find & Price Medications'. Here, you will be able to see how many tiers your plan has and what you pay for each tier. Drugs approved by the U.S. Food and Drug Administration and covered by your insurance should be listed in your plan's drug list.
If you are already at the pharmacy, you can also ask the pharmacist whether the prescription you are picking up is covered by your insurance. They can check your insurance information on file and tell you what you will pay and what your insurance may pay. You can also ask the pharmacy if there are any ways to lower the cost, such as equivalent drugs or programs to help with your costs.
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Call your insurer or pharmacist to check coverage
If you are unsure whether you have prescription insurance, calling your potential insurer or pharmacist is a good way to check your coverage. This is also a good way to find out what a medicine will cost you. You can also ask about the cost of your prescription at different pharmacies. When your doctor sends a prescription to the pharmacy, the pharmacy will check your insurance information on file when they fill your prescription. They can tell you what you will pay and what your insurance may pay. If the cost is higher than you expected, there may be ways to lower it, such as checking if there is an equivalent, less expensive drug available.
If you are already at the pharmacy, you can ask the pharmacist whether the prescription you are picking up is covered by your insurance. You can also ask your insurer about whether your regular pharmacy is in-network under your plan, and if not, which pharmacies in your area are.
If you are unsure about your insurance coverage, calling your insurer is a good way to find out. You will need to have your plan information available, which you can find on your insurance card, the insurer's website, or the detailed plan description in your Marketplace account. You can also review any coverage materials that your plan mailed to you. If you are unsure about a specific prescription drug, you will need to know the name of the drug and the prescribed dosage.
It is also worth noting that sometimes, employers may have different coverage than what is published online. If you are unsure, it is best to call and check.
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Understand the different tiers of coverage
Understanding the different tiers of prescription drug coverage can be challenging, but it is important to know what your insurance plan covers. The list of covered prescription drugs is called a formulary, and it is usually divided into tiers or levels of coverage based on the type or usage of the medication. Each tier has a defined out-of-pocket cost that must be paid by the patient before receiving the drug.
There are typically three to five tiers of prescription drug coverage, with the higher the tier, the higher the cost of the medicine. For example, a 5-tier plan might include:
- Tier 1: Preferred, low-cost generic drugs
- Tier 2: Non-preferred, low-cost generic drugs
- Tier 3: Preferred brand-name and some higher-cost generic drugs
- Tier 4: Non-preferred brand-name drugs and some non-preferred, highest-cost generic drugs
- Tier 5: Highest-cost drugs, including most specialty medications
Specialty drugs are high-cost/high-technology drugs that require special dispensing conditions and may be listed in the highest tier or not listed at all. If a drug is not listed within any tier, it may not be covered under your insurance plan, and you may have to pay the full price.
It is important to research and choose a plan that covers your medication needs. You can find out what your plan covers by calling your insurance company, visiting their website, or checking your plan document. Additionally, your doctor or pharmacist may be able to help you understand your coverage and find alternative treatments if your medication is not covered.
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Check if your regular pharmacy is in-network
If you have prescription insurance, it's important to check if your regular pharmacy is in-network. This is because using an in-network pharmacy can help save you time and money.
To check if your regular pharmacy is in-network, you can try the following:
- Check the back of your health insurance ID card for a customer service phone number. Call this number and ask if your regular pharmacy is in-network.
- Check your insurance company's website for a customer service phone number or online tool. Some companies may also offer an app with this information.
- Log in to your member account on your insurance company's website or app. Here, you may be able to view a list of in-network pharmacies.
- Contact your insurance company and ask for printed resources that include a list of in-network pharmacies.
- Check if your insurance company has a preferred pharmacy network. For example, Cigna Healthcare members can use Express Scripts Pharmacy for home delivery, while Aetna Medicare members can use CVS Caremark® Mail Service Pharmacy.
- If you are a UnitedHealthcare member, you can use the Optum Rx pharmacy network to view general network pharmacy locations.
- If you have a Medicare Advantage prescription drug plan (MAPD), you can sign up for mail-order prescriptions to save time and avoid running out of your medications.
Remember, it is important to confirm your plan's specific coverage details before filling a prescription. Your plan's pharmacy network may include a variety of pharmacies, from large retail chains to smaller independent shops, so you may have options if your regular pharmacy is not in-network.
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Appeal a denied exception request
There are several ways to find out if you have prescription insurance. One way is to call the number on the back of your insurance card. Alternatively, you can ask the pharmacist at the pharmacy whether the prescription is covered by your insurance. Most insurance companies also have portals and mobile apps that can help you price a drug based on your current insurance plan coverage benefits.
If your exception request is denied, you have the right to appeal the decision. Each insurance plan has its own form for exception requests, and each plan has rules about how long it takes to review an exception request. Work with your healthcare professional or the individual at your provider's office who is responsible for developing and submitting exceptions.
If you disagree with the coverage decision, you can start the appeal process through your plan. Your plan will send you a denial letter with information on your appeal rights. You can request a redetermination, which is a Level 1 appeal in a Medicare drug plan. If your plan upholds their denial in your Level 1 appeal and you disagree with the decision, you have 60 days to file a Standard Reconsideration with a Part D Independent Review Entity (IRE) to start a Level 2 review. If your Level 2 appeal is denied, you have 60 days to request a Level 3 appeal, which is a decision by the Office of Medicare Hearings and Appeals (OMHA).
To make your appeal stronger, you can ask your provider or supplier for any additional information. You can also appoint a representative, such as a trusted family member or friend, to help you with your complaint. You have the right to a fast appeal if you think your Medicare-covered services are ending too soon.
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Frequently asked questions
You can call the number on the back of your insurance card to find out. You can also visit your insurer's website or use their mobile app to check. If you're at a pharmacy, you can ask the pharmacist whether your prescription is covered by your insurance.
If your prescription drug is not covered by your insurance, you can appeal for an exception to the plan formulary (a list of covered drugs). If the exception is granted, your health plan will cover the drug and you will be charged the copay amount associated with the highest tier of your drug plan.
If your exception request is denied, you have the right to appeal the decision.
You can log in to your insurance account and look under \"Pharmacy\" to see if your prescription drug is in-network. You can also call your insurance company or visit their website to find out.
