Prescription Service Insurance: What You Need To Know

Prescription service insurance is a type of health insurance that covers the cost of prescription medications. Depending on the insurance plan, coverage may also include hospital visits, outpatient care, emergency treatment, and surgery. While most Medicare Advantage plans include drug coverage, the cost of medications does not count towards the plan's out-of-pocket limit. Prescription medications can be costly, and specific drugs covered by insurance companies vary depending on the plan. It is important to consult with your insurance provider to determine which medications are covered and understand the exceptions process for requesting coverage for drugs that are not typically included in the plan.

Prescription drug coverage

Prescription service insurance is a type of health insurance or plan that helps pay for prescription medications. There are two main ways to get Medicare prescription drug coverage. The first is to join a Medicare Advantage Plan (Part C) or other Medicare health plan that includes drug coverage. The second option is to join a separate Medicare drug plan (Part D) in addition to your Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance). It is important to note that Medicare Part B only covers a limited number of outpatient prescription drugs under certain conditions, such as drugs administered in a doctor's office or hospital outpatient setting.

If you have prescription drug coverage through your insurance, it is important to understand what prescriptions your plan covers. This information can be found by reviewing your Summary of Benefits and Coverage, contacting your insurer, or activating your online account. Additionally, some insurance companies may provide a one-time refill for your medication when you first enrol. If your required medication is not covered by your plan, you have the right to appeal the decision and request an exception. To get your drug covered through the exceptions process, your doctor must confirm to your health plan that the drug is appropriate for your medical condition, and the request may then be reviewed by an independent third party.

Medicare Part B

Prescription service insurance is a health insurance plan that helps pay for prescription medications. Medicare Part B is one such insurance plan that helps cover medically necessary services and preventive services. It is important to note that Part B covers prescription drugs administered in a hospital outpatient setting and not "self-administered drugs".

Part B also covers HIV prevention drugs, injectable osteoporosis drugs, and erythropoiesis-stimulating agents for patients with End-Stage Renal Disease (ESRD) or anaemia. Furthermore, it covers certain vaccinations, including flu shots, pneumococcal shots, COVID-19 vaccines, and Hepatitis B shots for those at medium to high risk.

Self-administered drugs

Health insurance plans can help pay for prescription drugs and medications. Medicare Part B (Medical Insurance) covers a limited number of outpatient prescription drugs under certain conditions. Typically, Part B covers drugs administered by a medical professional in a hospital outpatient setting or doctor's office, rather than self-administered drugs. Drugs administered through an IV, through the muscle, or into the skin are not considered self-administered drugs. On the other hand, oral medications, suppositories, topical medications, and inhaled drugs are generally considered self-administered.

If you are enrolled in Medicare Part C (also known as Advantage), your plan will offer the same coverage as Original Medicare, which does not pay for self-administered drugs. However, some Advantage plans include prescription drug coverage. If your self-administered drug is not on the provider's list of covered drugs, you may need to claim reimbursement. Private insurance companies offer Medicare Part D plans, which generally cover brand-name and generic drugs. Part D covers regular prescription medications obtained from a pharmacy. However, it is important to note that Part D does not cover over-the-counter drugs, and hospital pharmacies often do not contract with Medicare Part D. Therefore, if you are hospitalized or receiving outpatient treatment, you may need to obtain your medications from the hospital pharmacy, which could result in additional costs.

In a hospital outpatient setting, Medicare Part B does not cover self-administered drugs, and you will be responsible for the full cost of the medication. However, under very limited circumstances, Medicare may pay for some self-administered drugs if they are necessary for your outpatient services. If your health insurance company refuses to pay for your prescription, you have the right to appeal the decision and request an independent third-party review. Additionally, your insurance company may provide a one-time refill for your medication when you first enrol, or you can follow their drug exceptions process to obtain a prescribed drug that is not typically covered by your health plan.

Health insurance policies

To understand what prescriptions are covered by your insurance, you can review the list of covered prescriptions on your insurer's website or in the Summary of Benefits and Coverage provided by your insurance company. This document can usually be found in the detailed description of your plan or by contacting your insurer directly. It's important to note that some insurance companies may provide a one-time refill for your medication, which can be helpful if you need to discuss next steps with your doctor.

If a medication you require is not on your plan's list of covered prescriptions, you may be able to follow your insurance company's drug exceptions process to request coverage for that specific drug. This process typically requires your doctor to confirm to your health plan that the requested drug is medically necessary and more effective or safer than the alternatives covered by your plan. During the exceptions process, your insurance company may temporarily provide access to the requested drug until a final decision is made.

Additionally, it's worth noting that the cost of medications may not count towards your plan's out-of-pocket limit, as this limit typically applies to services and not prescription drugs. However, the Inflation Reduction Act's limits on out-of-pocket costs for Part D prescription drug coverage can provide additional protection in this regard. Overall, it is important to carefully review the details of your specific health insurance policy to understand the extent of prescription medication coverage and any associated costs or limitations.

Costs and affordability

The cost of prescription medications can be high, and even with insurance, prescriptions can be expensive. This is where health insurance policies can help ease the financial strain. Almost everyone can benefit from having prescription drug insurance.

Prescription drug coverage is a standard inclusion for most health insurance plans. However, the specific drugs/medications covered by each insurer will differ. There is a formulary or list of permitted medications specific to each health insurance plan. Health insurers are allowed to develop their own formularies and adjust them as necessary, although they must comply with various state and federal rules. Within the formulary, drugs are divided into tiers, with the least expensive drugs typically in Tier 1 and the most expensive drugs listed in a higher tier, usually 4, 5, or 6.

It is important to educate yourself about your benefits and options and what kind of coverage you have. You should consult your insurance provider to determine whether the medication you need is covered under its plan. You can review a list of prescriptions your plan covers by visiting your insurer's website or calling them directly. You can also review your Summary of Benefits and Coverage, which you can get directly from your insurance company or through your Marketplace account.

If your health insurance company won't pay for your prescription, you have the right to appeal the decision and have it reviewed by an independent third party. You can also follow your insurance company's drug exceptions process, which allows you to get a prescribed drug that's not normally covered by your health plan. For example, your doctor must confirm to your health plan that the drug is appropriate for your medical condition, and all other covered drugs have not been or will not be as effective.

Frequently asked questions