Heading to the pharmacy to fill your prescription is a task everyone completes at least a few times a year; for some, it’s a daily activity. Even with the best planning, pharmacy issues will arise from time to time. To help, Debi Reissman, director of pharmacy benefits for Sharp Health Plan, answers your top prescription-related questions.
What do you do if your medication isn’t covered?
Talk to your doctor to see if another medication is covered on your health plan formulary, which is a list of prescription drugs covered by a specific health care plan. If your doctor is unable to find an alternative, he or she can submit an exception request to the health plan to request coverage for you. Your health plan will review and make a decision based on the clinical criteria for that drug.
What is the benefit of using a generic?
Most health plans do not cover a brand-name drug when a generic is available. Luckily, using a generic provides an equally effective and safe product at a lower cost. Using generics also help keep premiums and copays as low as possible.
Why can’t I get a drug I saw on TV or in a magazine ad?
Medications advertised on television are generally newer, high-cost brand medications. Generally, effective lower-cost alternatives are available on the health plan formulary for trial before moving to a more expensive product. If medications on the health plan formulary don’t work for you, your doctor can submit an exception request for an advertised product if your doctor deems it medically necessary for your condition.
Am I at risk if I buy medication online?
Maybe. You are especially at risk if you are buying online through a mail-order service not associated with your insurance plan. Many online pharmacies are located out of the country and the medication you request may not be what is advertised. Plus, this pharmacy cannot check your medication against other medications you are taking if they are not linked to your health plan pharmacy network.
If you go through a health plan mail-order pharmacy, ordering medication online is a safe, convenient and cost-effective way to obtain drugs.
What if I am traveling and need my prescription filled?
Try to plan ahead. Make sure you have enough medicine to last throughout your vacation, and if you do not, ask your doctor to ask the health plan for a vacation override. If you are traveling within the United States, most chain pharmacies can work with your health insurance plan to fill any prescriptions you need under your benefit. If you are traveling out of the country or experiencing an emergency, your health insurance plan can reimburse you — after you fill out a reimbursement form and submit a receipt.
Find more information about pharmacy and prescription drug benefits at Sharp Health Plan.