Prescription Drug Coverage: Do You Understand Yours?

Imagine choosing a health insurance plan, through your employer, the Health Insurance Marketplace, or even directly from an insurance company.  You pay your monthly premium and then you go to the pharmacy to fill your very expensive prescription, only to be told that your insurance doesn’t cover the prescription that your doctor gave you.

Now what?

  • Pay for the prescription out of pocket?
  • Don’t fill the prescription?
  • Go back to your doctor and ask if there is another drug you can take that is covered? (what if the answer is no)
  • Change your insurance plan? (wait – you can’t do that until open enrollment or until you qualify for a special enrollment period)

How can we avoid a situation like this?  We can’t.

Not unless we have access to clear, understandable information on what drugs are covered by each health plan (formulary = list of drugs covered) and at what level of coverage (tiers = different levels of formulary coverage).

Plans sold on the federal Health Insurance Marketplace (www.HealthCare.gov) provide this information now.  When you look at your plan options, you can actually click a link to see the plans formulary and check to see if your drugs are coverage.  You can also see a list of providers who are covered.

Rx Chart

Most state-run Health Insurance Marketplaces don’t provide this information.  And this gap in information has a serious impact on the cancer community.

California currently has a bill waiting for the Governor’s signature (SB1052) to try to address this issue in California, by requiring the:

  • State Marketplace (Covered California) to create a search tool, to allow consumers to search for plans that cover specific prescriptions drugs
  • plans to provide a complete formulary on their website and keep it up to date
  • plans to explain your out of pocket costs for prescription drugs
  • plans to explain if certain prescription drugs have restrictions, like requiring a pre-authorization before you can get access to a drug

For more information, about using your prescription drug coverage, visit: www.healthcare.gov/using-your-new-marketplace-coverage/#part=2.

For more information about SB1052, visit: http://leginfo.legislature.ca.gov/faces/billVotesClient.xhtml or click here.

Triage Cancer
info@triagecancer.org