Guide To How Prescription Benefits Work

There are many drug or prescription plans out there that you may have subscribed to. The first thing you need to remember is to always go for a network pharmacy (unless it is an emergency and you don’t have a choice). When you get a drug plan, you have to show your ID when you go to get your medicines at the pharmacist. The bill would be submitted by the pharmacist on your behalf. Unless your network has some other rules, paper claims should never be sent in.

Here is how drug benefits work –

Three Tier Levels – There is a tier system – Tier I, Tier II, and Tier III. The tier you choose would decide the copay option you want to go for. This means that the lowest option is Tier I and the highest option is Tier III. With Tier I, your out of pocket expenses would be the lowest and with Tier III, they would be the highest. Tier II is chosen if no Tier I drugs can be found that would help you with your condition. Tier III is for the more expensive drugs but usually, you can ask your provider if any Tier I or II options might be used instead.

Network Pharmacy and Home Delivery – You can choose to get your prescription filled by visiting a network pharmacy or choosing home delivery option to get your drugs from the comforts of your own home. You don’t need any claim forms to fill when getting your drugs. The supply is up to 31 days and for home delivery, this becomes 90 days. You can have your drugs refilled via phone or even by logging in online to the network. You don’t have to pay the full cost of the drugs and, depending on the tier, you end up saving quite a lot. For instance, in Tier I, the copay amount is usually around $10; in Tier II, it is usually around $25; and for Tier III drugs, the amount is around $50.

Other Coverage – Preventative OTC medications have 100% coverage if you fill them at a network pharmacy. Same goes for female contraceptives like emergency contraceptives, diaphragms, hormonal contraceptives, and OTC contraceptives. These should be prescribed by your healthcare provider. Male contraceptives are not always covered. Many drug benefits plans offer a Preferred Drug List that your healthcare provider could consult, if they want.

Finally, generic drugs are cheaper and so, when your doctor prescribes something to you, make sure you ask whether the drug is generic. If not, ask if there are generic alternatives available. These benefits can be extremely helpful in lowering the cost of medicines for you and your family in the short and long term.