Hello friends. Welcome back to my blog. Suppose you see a doctor at urgent care or are discharged from an emergency room. In that case, they usually fax your prescription directly to your pharmacy so you don’t have to carry paper around, and the prescription will be ready when you arrive. If you don’t have a pharmacy set up, you need to know whether the medication is covered by insurance or you have to pay cash for it. To determine if your medication is covered by your insurance, you can try out these options:
Take it straight to the pharmacy.
Give them your insurance info and ask them to run the prescription through. Make sure to give pharmacy times because they can be very busy. Once they run it through, they will let you know whether you have any copay.
Review your insurance policy.
Start by locating your health insurance policy documents or the member handbook provided by your insurance company. Look for prescription drug coverage information, including specific lists or formularies that outline covered medications.
Formulary check.
If your insurance plan has a formulary, it will typically categorize medications into different tiers based on their cost and coverage. Check the formulary to see if your medication is listed and in which tier. Medications in lower tiers usually have lower out-of-pocket costs.
For instance, I have OptumRX as my insurance for medication.OptumRx is a pharmacy benefit management (PBM) company that provides medication insurance services. As a PBM, OptumRx works with insurance companies and employers to manage prescription drug benefits for their members. While OptumRx is a reputable and well-known company in the healthcare industry, it’s important to note that medication insurance quality and satisfaction can vary based on individual experiences and specific insurance plans. Here is how to navigate through OptumRX website to see their formulary.
Step 1: Log into their website. You don’t have to be a member to see this information.
Step 2: If pricing is your main concern, check out “Drug Pricing Tools” option
Step 3: Select one of the 2 plans:
HealthSelect of Texas and Consumer Directed HealthSelect are both health insurance plans offered to employees and retirees of the Employees Retirement System of Texas (ERS). Here’s a breakdown of the key differences between the two plans:
- Consumer Directed HealthSelect (CDH): Consumer Directed HealthSelect is a high-deductible health plan (HDHP) that is paired with a health savings account (HSA). CDH aims to empower participants to take control of their healthcare spending and engage in cost-conscious decision-making. With CDH, you have a higher deductible that you must meet before the plan starts covering most services. However, you can contribute to an HSA, which allows you to save pre-tax dollars to pay for eligible medical expenses. The HSA funds can accumulate and roll over from year to year, providing a tax-advantaged way to save for future healthcare costs.
- HealthSelect of Texas (HST): HealthSelect of Texas is a traditional preferred provider organization (PPO) plan. It offers comprehensive coverage with a focus on access to a broad network of providers. With HST, you have the flexibility to choose any doctor or specialist within the plan’s network without needing a referral. You can also receive care outside the network, but at a higher cost. HST provides coverage for a wide range of medical services, including hospitalizations, doctor visits, prescription medications, and preventive care.
Since I have PPO with my hospital, I will select HealthSelect of Texas
Step 4: Fill in the area you want, select the radius you like and hit “Apply”
Step 5: Type in your drug name. I use Brilinta, which is a blood thinner that can prevent stroke, heart attack, and other heart problems, as an example. Below are the pricing based on your local pharmacies
It looks like my copay is $95 for 1 month’s supply. I hope this instruction help you or your family members.
Contact your insurance company
Reach out to your insurance company directly to inquire about your medication coverage. The contact information is usually provided on your insurance card or on their website. Speak with a representative or use their online tools to check if your medication is covered and what costs you might be responsible for.
Prior authorization or step therapy
Some medications require prior authorization or step therapy. Prior authorization means your doctor needs to submit additional information to the insurance company to demonstrate medical necessity. Step therapy means you may need to try certain alternative medications before the insurance will cover the prescribed one. Check if these requirements apply to your medication.
Preferred pharmacies or mail-order options
Insurance plans sometimes have preferred pharmacy networks or mail-order options that offer lower copayments or cost-sharing for prescription drugs. Confirm if your insurance covers your pharmacy or mail-order service for the specific medication you need.
Insurance coverage can change over time, so it’s essential to stay updated. Verify whether any recent changes have been made to your insurance policy, such as updates to the formulary or modifications to the coverage of specific medications. Remember, it’s always recommended to consult with your insurance provider directly for the most accurate and up-to-date information about your medication coverage.
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