Does my plan cover my medications?

Most health plans include comprehensive prescription drug coverage that are designed to reduce your out-of-pocket costs. It’s important to understand while you have access to a wide range of medications, any pharmacy drugs on your plan’s approved list (also known as a formulary) are typically less expensive.

To better understand prescription coverage for your health plan:

  • Visit your insurance company’s website or call them to review the prescriptions your plan covers and how much you’ll have to pay in out-of-pocket costs:

 

Health Insurance Company Pharmacy
Resources
Formulary Customer Service
Blue Cross & Blue Shield of Rhode Island Click here Formulary 1-855-690-2583
Neighborhood Health Plan of Rhode Island Click here Formulary 1-800-459-6019

 

  • Review the Summary of Benefits and Coverage for your plan by:
    • Login to your health insurance company’s online account
    • Login to your HealthSource RI account page, and click on the detailed description of your health plan,
    • Find your plan and your plan details through the HealthSource RI Savings Tool.
  • Review coverage materials that your insurance provider mailed to you.
How are prescription drugs classified/What are prescription drug tiers?

Brand-Name Drugs

Brand-name drugs have been developed by the company that holds the legal rights to sell them. When those rights expire, other drug companies can make a copy of the brand drugs (generics). Brand-name drugs may be more familiar to a consumer because they are advertised more frequently. Brand-name drugs are usually more expensive than generics.

Generic Drugs

Generic drugs are either copies of brand-name drugs or brand-name drugs with patents that have expired. Brand-name and generic drugs have the same active ingredients, strength and dose. The U.S. Food and Drug Administration (FDA) requires that generic drugs meet the same high standards for purity, quality, safety and strength. Generic drugs are almost always less expensive than brand-name drugs.

Preferred, Non-Preferred and Specialty Drugs

Health plans often structure their formularies into pricing groups/drug tiers. Some drugs are in lower-priced groups and cost you less money. Other drugs are in higher-priced groups and cost you more money. Preferred drugs are usually the cheapest for both you and your insurance company. Non-preferred and specialty drugs are the most expensive, both for you and your insurance company.

Drugs on the FDA Select Drug List are grouped into tiers. Several factors determine which tier a drug is placed in. These factors include:

  • The cost of the drug
  • The cost of the drug in comparison to other drugs used for the same type of treatment
  • The availability of over-the-counter options
  • Other clinical and cost factors

Prescription drug lists are always changing. For the most current information, check with your health insurance company.

What do I do if I’m at the pharmacy and they say my plan no longer covers my medication?

In some instances, health insurance companies will offer a one-time refill of your medication after you first enroll in a new plan. Ask your insurance company if they offer a one-time refill until you can discuss next steps with your doctor.

If you are unable to get a one-time refill, you have the right to follow your insurance company’s drug exceptions process, which lets you request prescribed drug that’s not normally covered by your health plan. Because the details of every health plan’s exceptions process are different, you will need to contact your insurance company for more details.

Generally, to request prescription drug coverage through the exceptions process, your doctor must confirm to your health plan (orally or in writing) that the drug is appropriate for your medical condition based on one or more of the following:

  • All other drugs covered by the plan haven’t been or won’t be as effective as the drug you’re asking for
  • Any alternative drug covered by your plan has caused or is likely to cause side effects that may be harmful to you
  • If there’s a limit on the number of doses you’re allowed:
    • That the allowed dosage hasn’t worked for your condition, or
    • The drug likely won’t work for you based on your physical or mental makeup. For example, based on your body weight, you may need to take more doses than what is allowed by your plan.

If your exception is approved:

  • In most cases your health plan will approve the drug as covered and charge you the copayment that applies to the most expensive drugs already covered on the plan (for example, a non-preferred brand drug).

In many cases the amount you pay for the drug generally will count toward your deductible and/or maximum out-of-pocket limits, you will need to confirm this practice with your health insurance provider.

Here are some useful links:

Blue Cross & Blue Shield of Rhode Island

Neighborhood Health Plan of Rhode Island

Can I get the non-covered drug during the exceptions process?

While you’re in the exceptions process, your plan may give you access to the requested drug until a decision is made.

Can I go to my regular pharmacy to get my medication?

Just like how different health plans cover different medications, different health plans allow you to get your medications from different pharmacies (called “in-network pharmacies”). Contact your insurance company or visit their website to find out whether your regular pharmacy is in-network under your plan and, if not, what pharmacies in your area are in-network. You can also learn about any prescription delivered services that are offered by mail.

HealthSource RI connects you with health and dental insurance from these companies:

Individuals & Families: 1-855-840-4774
Employers & Employees: 1-855-683-6757