Private Health Coverage

Every health coverage plan is different, but there are a few general rules that can help you figure out what medications your private health coverage will help you pay for and how much you will have to pay out of your own pocket when you get medications.

While we’ll explain a few of the most common rules here, you will have to check with your health coverage provider or your employer’s Human Resources department to get the details of how they work in your plan:

• Most health coverage plans will not pay for every medication that your doctor may prescribe for you. Formularies are a list of drugs that your health coverage plan will pay for. If you get a prescription for a medication that is not on your formulary, your health plan won’t pay for it. To learn what is in your formulary, you need to speak with your plan manager.
• Most health coverage plans require you to pay a copayment every time you get a medication. That means that while the health coverage pays for most of the expense of the medication, you have to pay a certain amount each time you get a prescription filled. Usually, generic medications require a lower copayment than brand-name medications. For example, you may have to pay $10 every time you get a generic medication, but $30 every time you get a brand-name medication.
• Some health plans have deductibles. If your plan has a deductible, you will have to pay the entire cost of any medical charges until you have spent a certain amount. For example, each year you may have to pay the first $2,000 in medical expenses before your health coverage plan will help you pay for medical expenses, including prescription drugs. Some plans may have a deductible for brand-name medications, but not for generic medications.