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Know Your Plan: Questions to Ask

Here are some questions to get you started in understanding your health insurance plan's pharmacy benefit:

• Does the plan require that my doctor and I choose medicines from a formulary, or list of covered medicines?
• If so, are my prescriptions on the plan's formulary? If I need a medicine that is not on the formulary, will I have to pay for it myself, or will the plan reconsider its decision based on an appeal?
• What is the process for pursuing an appeal?
• How much are my co-payments, or what I owe the pharmacy when I get a prescription?
• What are the different levels or tiers of co-payments? What types of medicines are in each tier, and what is the amount for each? Do my different medicines fall into different tiers?
• Is there a penalty if I don't want to use the mail order service? Will the plan require that I use it, or can I choose to get medicines I use regularly at my local pharmacy?
• Is there a limit to my out-of-pocket expenses? Does it include the amount I pay for my medications?
• Is there a cap (limit) on my total benefits? Is it possible that I could use up all my benefits and have to pay full price myself for anything else I need?
• If there is a less expensive medicine than the one my doctor prescribes for me, will my health plan force me to try the cheaper one first? (This is called step therapy.)
• Will the health plan ever call my doctor to ask him or her to switch me to a different, cheaper medicine? (This is called therapeutic substitution.)
• Does the health plan require approval for certain medicines before it will pay for them? If so, how is this prior authorization obtained?