Prescriptions and Insurance Plans

Getting a prescription filled is usually easy. But because of the high cost of prescription medicines, most insurance companies and employers are trying to control drug costs. Some of the things they are doing make getting a prescription more complicated for you and your doctor, and some of the terms they use can be confusing.

What is a formulary?

A formulary is a list of medications that your insurance company will help you pay for. This list is reviewed and changed by the insurance company every few months.

The drugs in a formulary are often listed in 2 or more groups, depending on how much of the cost you are expected to pay. The amount you’re expected to pay is called your co-pay. A typical formulary might include the following groups (also called levels or tiers):

GroupDrugsCo-pay size
Level 1Generic drugs$
Level 2Preferred$$
Level 3Non-preferred brand-name drugs$$$

The more dollar signs in the table, the higher the co-pay amount.

What’s the difference between a brand-name drug and a generic drug?

When a drug company develops a new drug, it gives it a brand name. Brand names are the names you usually see in ads on TV and in magazines–names like Claritin and Advil.

For several years after the drug is developed, laws prevent other drug companies from copying it. When other companies start manufacturing and selling the drug, their versions are usually known by a different name–the generic name. This is often the chemical name. For instance, the generic name of Claritin is loratadine and the generic name of Advil is ibuprofen.

Generic drugs are chemically the same as brand-name drugs, and they are often less expensive. That’s why many insurance plans encourage you to use generic drugs.

What are preferred and non-preferred drugs?

Often 2 brand-name drugs help treat the same problem. Your insurance company may be able to get one less expensively than the other. That drug becomes a preferred drug, and the other becomes non-preferred. That’s usually why you pay more for non-preferred drugs.

Sometimes an insurance company will move a drug from the preferred list to the non-preferred list. If this happens to you, your doctor might be able to prescribe a preferred drug that would cost you less money and work just as well for you.

What about drugs that aren’t in the formulary?

Formularies include a limited number of drugs. Many don’t include drugs that the insurance companies believe aren’t necessary to improve health. These are sometimes called lifestyle drugs. Weight loss and hair growth drugs are examples of lifestyle drugs. Your insurance company won’t help you pay for a drug that isn’t part of its formulary.

How can I make filling a prescription easier?

Here’s what you can do to reduce the chances of having a problem when you try to fill your prescription.

If you don’t have a copy, you can call the customer service number listed on your insurance card and ask to have one mailed to you. You can also ask the customer service representative whether a specific drug is covered and what the co-pay will be for that drug. If you have access to the Internet, you should be able to find your plan’s formulary on its website.

Insurers don’t always use all pharmacies. They make deals with certain pharmacies. If you have your prescription filled at a non-participating pharmacy, you may pay a higher price. Ask the customer service representative what pharmacies participate in your insurance plan.

The number of times you can get the prescription refilled should be printed on the label. While you have refills remaining, you can go directly to the pharmacy to get a new supply of medicine. If you are taking the drug over a long period, you’ll need to call your doctor’s office for a new prescription when you have no refills left. The doctor may want to see how you’re doing before prescribing more of the medication.