Employer-sponsored health plans are one of the most common sources of health insurance in the United States, and prescription drug coverage is a standard component of these plans. While most employer plans include medication benefits, the structure, costs, and coverage rules can vary widely. Understanding how prescription drug coverage works in employer-sponsored plans helps employees … Read more
High-deductible health plans (HDHPs) combine lower monthly premiums with higher deductibles, shifting more upfront costs to the policyholder. Prescription drug coverage under HDHPs follows different rules than traditional plans, especially early in the plan year. Understanding how prescription drug coverage works with HDHPs helps individuals anticipate costs and manage medication expenses more effectively. Prescription drugs … Read more
Quantity limits are restrictions set by health insurance plans on the amount of a prescription medication that can be dispensed within a specific time period. These limits are a common feature of prescription drug coverage and are used to promote safe medication use and control costs. Understanding how quantity limits work helps policyholders avoid coverage … Read more
Step therapy is a coverage rule used by health insurance plans to manage prescription drug costs while promoting effective treatment options. Under step therapy, a policyholder must try one or more lower-cost or preferred medications before the insurance plan will cover a higher-cost drug. This process is sometimes referred to as “fail first” because coverage … Read more
Prior authorization is a requirement used by health insurance plans to review and approve certain prescription medications before coverage is provided. This process ensures that medications are used appropriately and helps control prescription drug costs. While prior authorization can be an effective cost-management tool, it can also affect how quickly a patient receives medication. Understanding … Read more
Mail-order prescription drug programs allow policyholders to receive medications by mail rather than picking them up at a retail pharmacy. These programs are commonly offered by health insurance plans as part of their prescription drug benefits and are often designed to reduce costs and improve convenience for long-term medications. Understanding how mail-order prescription programs work … Read more
Pharmacy networks are a key part of how health insurance plans manage prescription drug coverage. These networks determine where policyholders can fill prescriptions and how much they pay. Understanding pharmacy networks and preferred pharmacies helps individuals avoid higher costs and ensure their prescriptions are covered. Even when a medication is on the plan’s formulary, where … Read more
A prescription deductible is the amount a policyholder must pay out of pocket for covered medications before the health insurance plan begins to share costs. Not all health insurance plans include a prescription deductible, but when they do, it can significantly affect medication expenses, especially early in the plan year. Understanding how prescription deductibles work … Read more
Copays and coinsurance are the primary ways health insurance plans share prescription drug costs with policyholders. These cost-sharing methods determine how much an individual pays at the pharmacy counter when filling a prescription. Understanding how copays and coinsurance apply to prescriptions is essential for estimating medication costs and comparing health insurance plans accurately. Although both … Read more
Specialty drugs are a category of prescription medications used to treat complex, chronic, or rare medical conditions. These drugs are often high-cost and require special handling, administration, or monitoring. Because of their expense and complexity, health insurance plans cover specialty drugs differently than standard prescription medications. Understanding how specialty drugs are covered helps policyholders anticipate … Read more