Did you know? Insurance and Pharmacy Choice

Did you know? Insurance and Pharmacy Choice


Insurance and Pharmacy Choice

As a patient and healthcare consumer, do you know the prescription plan benefits of your health insurance? Some prescription drug plans will not allow you to use your local pharmacy and require you to use a large chain or mail order pharmacy which will be considered preferred and in network. Just like certain physicians and health care providers are considered out of network, the same goes for your local pharmacy. It pays to know what your commercial plan, Medicare Part D, or Healthcare.gov plan allows, especially if you are planning to use or continue to use one of your local independent pharmacies. Premium price may not always be the only factor when considering your individual needs.

What can you do?

  1. Talk to your employer and find out about what the prescription drug benefits of your commercial plan allow. What medications are covered and what pharmacies can be used?
  2. Choose your Medicare Part D supplement wisely. While price may be one of the factors to consider, you should also factor in what medications you take (are they covered?) and where you would like to purchase your medications. If you have been using your favorite local pharmacy, make sure that it is still allowed under your new plan. This plan should be reviewed every year to make sure that nothing has changed about your coverage. Many local pharmacies including D&H offer to help research your plan during the open enrollment period from October 15 – December 7. Once you have made your decision on coverage, there are even resources like CLAIM in Missouri to help you sign up if you need assistance.
  3. Choose your ACA Health care plan accordingly. If you don’t currently have insurance or have a life changing event (marriage, baby, moving or loss of coverage), you may qualify for a special enrollment period. If you do, you can fill out the coverage application and research your eligible plans and pricing. Before making a decision, you can reference the individual plan to find out if your physician, health care provider, medications and pharmacy are covered. You will have to go the individual plan’s web site and find a Summary of Benefits and Coverage for your plan or contact them directly.

Important Note: Just like you do your research in the beginning, you should research when medications change or your health condition changes. If you are being prescribed a new medication, it is best to make sure:

  1. It is covered by your insurance
  2. You can get that medication from your favorite pharmacy

When you receive a new prescription, you may want to call to get details. In certain circumstances, your physician may have to prescribe an alternative medication if the one that they want to prescribe is not covered unless you want to pay for it.

For additional information on pharmacy choice for consumers, visit NCPA: http://www.ncpanet.org/advocacy/pharmacy-choice#consumer


Image from NCPA