Many of the calls and questions I get from clients is in reference to prescription drug coverage. Sometimes, trips to the pharmacy can cause additional headaches, but there may also be some things you can do as a consumer to help make sure you are being given all of the options and get the best possible outcome.
What is the typical process when filling a script?
When your prescription is given to a pharmacy to be filled, they run your information through their systems – they look up your coverage information with the insurance company and see how the company covers that prescription on something called a formulary list. This is why it crucial that you are giving your pharmacy your updated insurance information because each insurance company will have a different formulary list. This formulary list is also subject to change throughout the year if the insurance company feels it necessary. Your script goes through without a problem and the pharmacy will hand over your medication exactly as the doctor prescribed, and you’ll be told your cost share based on your plan and contract with your insurance company. The cost share may be applied to your deductible, or coinsurance, or you may just have a prescription copay – and that’s it. Simple right!?
What can go wrong and what does it mean?
What happens when getting a script filled does not happen easily and the pharmacy gets an error message on their computers? Most times, people will tell me the pharmacy relayed to them there’s no coverage for their medication. Usually, the prescription just requires step therapy. Step therapy means that the insurance company feels that there is another medication in the same prescription class that should be able to do the same thing but costs less than the script your physician wrote. This isn’t the end of the story…. Once the pharmacy receives the error message that you drug requires step therapy, they should send the appropriate paperwork to your doctor to let them know. The doctor can either tell the PHARMACY to go ahead and dispense the lower cost alternative OR the doctor can tell the INSURANCE COMPANY they want the script as they originally prescribed and to give the reasons why. After the insurance company reviews the doctor’s request, they either approve and you get the script your doctor originally prescribed or the insurance company argues back and denies the medication. Many times, if the doctor is adamant in their original choice of prescription, the insurance company will approve. If you need to begin taking a medication immediately and the script requires step therapy or additional authorization, contact your doctor to see if they have samples, but if they don’t, your doctor should be able to offer a temporary solution while they take care of the insurance part.
What questions to ask the pharmacy when something doesn’t go according to plan?
So what can you do if you are at the pharmacy and they tell you there is no coverage for your script? Ask them, “is my prescription declined or does it require authorization?” If they answer that it requires authorization, ask them “will you send paperwork to my physician to complete?” If you are confused about the answer you receive and need some assistance, call our office, even while you are still at the pharmacy so that we can talk directly with the pharmacy staff if need be.
The biggest piece of advice we can offer, never be afraid to ask questions when you’re at the pharmacy – ask if there were any problems filling the script or if there is any additional information you should know. Also, never hesitate to contact us if you need assistance getting any of the answers you need, it’s why we’re here and why you’ve trusted us to be your agent, let us know how we can help!