Does Most Health Insurance Cover Prescription Costs?

Does most health insurance cover prescription costs? Generally, the majority of insurance policies do have a prescription co-payment for the member. "Yes, most plans cover prescriptions drugs," answers Cindy...

"Yes, most plans cover prescriptions drugs," answers Cindy J. Holtzman, Director of Operations at Medical Billing Advocates of America (MBAA). "Generally, the majority of insurance policies do have a co-payment for the member. It may come with a separate "Drug Card Deductible", other than your normal medical deductible." Your prescription costs will most likely be different than the co-payments you pay at the doctor's office for a check up, test, or whatever your medical need may be that day. Your cost is usually determined by whether your prescription is name brand or generic. The co-payment required will reflect that difference.


Ms. Cindy J. Holtzman provides the following information. "If you have a co-payment for your type of plan, it may be similar to the common plan example below:"




Category of Drug Co-Payment Cost To Member

Generic $0 to $15.00 (for a 30 day supply)
Brand Name $25.00 to $60.00 (for a 30 day supply)
Non-Formulary (not on the list) $60.00 to $100.00, or Not Covered At All


A non-formulary drug is a medication your insurance company has chosen not to include on their list of prescriptions covered. This may be because they've not yet examined the benefits of the drug because it is new to the market. More often, it is because there is a drug already on their list of approved medications that offers the same benefit. Obviously, cost is usually the reason they would choose one type of drug over another when they both perform similarly.

"Be aware that some insurance policies have an annual cap on their prescription benefits," warns Ms. Holtzman. A cap is the opposite of a deductible. The medical insurance will cover prescription costs up to a limit and after that all prescription costs will be out of pocket, meaning you would be paying the full price of the medication out of your own money. This would continue until the following year when your prescription coverage starts all over again. Be sure to check the details on your prescription plan within your medical insurance policy to see if there is an annual cap on the coverage provided. Fortunately, not all policies have this limitation.

There are prescription plans available outside of medical insurance that can sometimes be used in conjunction with your medical insurance prescription coverage. These are ideal if your co-payments are high and you use a lot of medications. Often there is a fee involved, but considering your personal prescription expenses, the fee may be substantially less than the savings, thereby well worth having.

Now a days, so many medical conditions can be fixed or managed with prescriptions medications. Because of this, the use of prescription drugs is more commonplace than ever before. However, prescriptions are expensive and very few people can afford their medications without prescription coverage. When choosing medical insurance keep this in mind and make sure your policy will help cover the costs of medications. Without that, should you or any of your family members become ill you could find yourself in financial distress. Many times it takes trying several different medications before finding the most effective one and this adds up quickly. With even the most basic prescription coverage you should be able to manage financially without problem.

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