Prescriptions and Health Insurance Explained

Most health insurance which is purchased either privately or through a group plan has a clearly detailed policy regarding prescription medications. The plans may only cover specific medications or they may only cover a percentage of the cost of medications. Some plans may not have prescription drug coverage at all. It is important that individuals review their health care insurance policy to find out exactly what is covered under the plan and if the plan has an annual or lifetime cap on the amount it will pay for drugs.

Medicare Part B

Unlike private healthcare plans, Medicare, the government subsidized healthcare insurance for the elderly,  is unclear and confusing on prescription drug coverage. Drug coverage under Medicare  contains a donut hole where no coverage is available. The donut hole is a mid range area where Medicare has paid a certain amount for prescriptions and will not pay for additional medications until the insured person spends a predetermined amount of their own money (or uses other insurance coverage) on drugs.

Medicare Supplements

Many Medicare supplements provide coverage for medications not covered under Medicare Part B. As with any private insurance plan, some prescription medications may not be covered so it is best to check with the insurer when filling a new prescription. In some cases medications may only be covered if they are administered in a hospital and not covered if given in a doctor’s office. Prescription coverage under Medicare and Medicare supplements is very specific, and must be checked on a case by case basis.

Private Prescription Insurance

In answer to the need for better prescription drug coverage, some insurers now offer supplemental prescription insurance which coverages at least a percentage, often 50%, of the cost of most medications. Some medications may be excluded from the coverage and the amount of the percentage may be determined by what the insurer would pay for the drug, not the actual cost to the consumer. The cost of supplemental prescription coverage is usually fairly low and it can save money on medications.

Health Insurance and Generic Drugs

Many insurance plans which cover prescription drugs require that the insured person use a generic brand of the drug rather than a name brand. For instance, Tylenol is a name brand of acetaminophen; acetaminophen is the generic name of the drug. Many prescription drugs have generic equivalents that are less expensive than the name brand and pharmacists can assist customers in changing prescriptions to covered generic equivalent medications.

Over the Counter Medications

Over the counter (OTC) medications are not covered by health or prescription insurance even if they are recommended by a doctor. Many Americans are on daily aspirin therapy for heart disease and they must pay for this medication themselves. Some doctors recommend particular vitamin supplements to treat a medical condition or disease and these supplements are not covered by insurance. As a rule, any medication which can be purchased without a doctor’s prescription is not covered by health or prescription insurance.

Before purchasing a supplemental prescription drug insurance policy, individuals with health insurance should review the coverage for prescriptions under their primary healthcare plan. Some HMO and PPO health coverage pays the cost of most prescription drugs, while other health insurance may not pay for any prescription medications. There really is no standard for prescription drug coverage in the U.S. so each individual must decide the best way to pay for necessary drugs.

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