Insurance coverage of prescription drugs has become more and more complicated. The following are terms you must understand to interpret your policy and optimize your cancer treatment.
- FORMULARY is a list of prescription medications which your insurance will help you pay for. Often the formulary will be listed online at your insurance company’s website or you may request a printed copy. The formulary may change several times a year.
- Tier is the level of drugs in the formulary which define how much you are expected to pay for them.
- Copay is the amount you are expected to pay for the drug.
- Level 1 of the tier is usually generic drugs which have a low copay.
- Generic drugs are chemically the same as brand name drugs but usually less expensive.
- Level 2 of the tier is brand name or preferred drugs which are more expensive prescriptions which require a larger copay.
- Brand name drugs are recently manufactured drugs which are protected by a patent. The patent limits competition in selling the drug since it may only be sold by the company which manufactures it. When the patent expires, other companies may manufacture generic versions of the drug subject to FDA approval. Competition increases so generic drugs are cheaper
- Preferred drugs are brand name drugs which an insurance company can get at a better price.
- Level 3 of the tier is non-preferred drugs which require a high copay.
- Non-preferred drugs may be very similar to preferred drugs but are more expensive to the insurance company
Destination RX /RXaminer is a website founded by a physician which can help you find alternatives to brand name drugs. Always check with your doctor before you change drugs.
Pre-certification may be required before a drug is covered by insurance. A physician must get prior authorization or approval from the company before prescribing the drug.
Step -Therapy medications have cheaper or generic versions which the insurance company requires be prescribed first. If the first step or generic drug doesn’t work or you have adverse effects, a physician can prescribe a brand name drug. Often these drugs must be “justified” by your physician and approval is on an individual basis. Sometimes if a physician insists on a step-therapy drug as a first step, an appeal can be made to the insurance company for coverage.
Quantity Limit is dependent on your prescription plan. Certain drugs may only be covered up to a specific quantity.
Price Cap is when an insurance company limits how much it will pay per year for medications.
Appeals Process. Contact your health plan or your state’s Department of Insurance to learn your rights and how to file an insurance appeal. To find this information by state, go to:
The National Association of Insurance Commissioners
Start your appeal with your physician. Precise records and persistence are key to the appeal process.
Contraindication is when two medications react badly when taken together.
Keep a list of all medicines on your Breast Cancer Advocate iPhone App and review with a doctor or pharmacist before adding a new one.
