Depending on your insurance provider, your prescriptions may or may not be covered. Most Americans have insurance that offers prescription drug coverage, but not all medications are covered. Health insurance plans are structured differently, but if your pharmacy charges a copay with your prescription, you may end up paying more for the medication than you would otherwise due to a concept called “clawback.”
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Reading: How much will my prescription cost with insurance
why is my prescription more expensive with insurance?
Each health insurance plan has its own policy when it comes to prescription drug coverage. the breakdown of costs associated with prescription drugs may vary by plan. Depending on your plan structure, you may pay more for your medication if your plan requires you to pay a set copay to the pharmacy for your medication. Regardless of the cost of your drug, you will be responsible for this copay, but sometimes your copay may be more expensive than the drug itself. this concept is known as “clawback”.
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A copay on prescriptions means that the insurer and patients share the costs of the drug. Alternatively, when a copay exceeds the cost of the drug itself, the Prescription Benefits Manager (PBM) keeps the difference as profit. a 2013 study found that prescription overpayments totaled $135 million. In 2019, a series of prescription drug price transparency measures, known as the PBM Prescription Drug Cost Transparency Act, were passed.
how insurance prescription drug coverage works
Prescription drug coverage varies by insurance plan and may be included with your benefits, or you may have to pay more for additional coverage on services such as dental, vision and prescription drug coverage. The list of prescription drugs covered by a health insurance plan is called a formulary. Depending on what your health care provider prescribes, you may have to pay for that prescription out of pocket if the drug is not on your plan’s formulary.
The cost of your prescriptions may depend on how costs count toward your deductible. Your plan likely falls into one of three categories when it comes to costs associated with medications:
drug coverage before you meet your deductible
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Health insurance plans may offer prescription coverage before you meet your annual deductible. Often, you may still need to pay a copay or coinsurance associated with your drug.
drug coverage after you meet your deductible
A health plan may require you to meet your annual deductible before your insurance provider will help cover your drug costs; This can mean you have to spend thousands of dollars before your plan helps you pick up expensive prescriptions.
drug coverage after a specified prescription deductible
Some health plans may require a deductible specifically for prescription drug coverage. These deductibles are typically much less than the thousands you must pay for your standard health coverage.
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