Filling Your Prescriptions (Individual and Family Plans)
Having your prescriptions filled is affected by your insurance plan's rules. These rules can cause delays in getting your prescriptions filled. They also affect out-of-pocket costs depending on the type of pharmacy you use.
Prescription Refill Delays
For certain medications, you may experience delays when getting your prescriptions filled. The information below explains some possible delays. Please contact your insurance carrier for assistance.
There are many reasons your pharmacy may be unable to fill a prescription for you under your health plan:
Your new plan is still processing
You haven't met step therapy requirements
You exceeded quantity limit restrictions
There’s a prior authorization or pre-certification for the prescription
Formulary changes occurred
You're using an out-of-network pharmacy
Your coverage lapsed
Step Therapy
Before some plans cover certain expensive drugs, they want to check that other more affordable drugs don’t work for you first. This may mean that you have to try multiple drugs before you can get coverage for the right medication.
In step therapy, drugs are grouped into two different categories:
· First-choice drugs (also known as front-line or first-step drugs) — These are the generic and lower cost, brand-name drugs that you will need to try before your insurer will cover the more expensive drug.
· Second-choice drugs (also known as back-up or second-step drugs) — These are the less preferred and more costly treatment options.
If you submit a prescription at the pharmacy for a drug that requires step therapy, your pharmacist will contact your physician, who will write you a 30-day prescription for a less expensive first-choice drug. If, after 30-days, that first-choice drug is not adequately treating your condition, your doctor can fill out an override, or exception form, and send it to your insurer to request that they cover the more expensive second-choice drug. This usually results in successful coverage, but unfortunately, your insurer can deny the request and leave you responsible for the full price of the medication.
Quantity Limits
A quantity limit restricts coverage of a drug to a certain amount over a certain period of time, such as 30 pills per month. Some drugs have quantity limits to help encourage appropriate usage, ensure effectiveness and reduce costs.
Prior Authorization
Before filling a prescription, a health plan may require a prior authorization (also known as a pre-certification) to make sure certain prescription drugs are used correctly and only when medically necessary. Before your health plan covers a certain drug, you must meet certain criteria for that particular drug.
Your insurance carrier can tell you what’s needed before filling your prescription. The phone number to contact your carrier is generally on the back of your Insurance ID card.
If you're currently unable to fill a prescription due to a prior authorization or pre-certification requirement, your physician may be able to request an exception from your insurance carrier.
In-Network Pharmacies
The most cost-effective way to fill your prescriptions is to use a preferred, in-network pharmacy (retail or mail order). Standard, in-network pharmacies are available, but you may have a higher copay or coinsurance amount than at a preferred pharmacy. If you use an out-of-network pharmacy, you may have a higher out-of-pocket cost. In some cases, you may have to pay the retail cost and submit a claim for reimbursement from the carrier.
The licensed benefit advisor* you speak with during your enrollment call can tell you which pharmacies are in-network for the health plans you’re considering.
If you’re already enrolled in a health plan, contact your insurance carrier or visit its website for a list of preferred and standard, in-network pharmacies (retail and mail order). The insurance carrier's phone number is generally located on the back of your Insurance ID card.
Contact the carrier for your prescription drug plan for information on filling your prescriptions using mail order. The phone number to contact your carrier is generally on the back of your Insurance ID card.
Please call us at 1-866-322-2824 (TTY: 711) for assistance if you’re having trouble reaching your carrier or need additional assistance.
*Our licensed benefit advisors specialize in health insurance for retirees. They go through annual training and certification to ensure they can help you make an informed and confident decision.