• What is the Health Insurance Marketplace?

    In 2014, new pieces of the health care law will take effect. This means you'll have a new way to get health insurance. The Marketplace is designed to help you compare and find health insurance plans that fit within your budget. Read more about the Health Insurance Marketplace at HealthCare.gov. You may also see it referred to as the Health Insurance Exchange.

  • I'm shopping for insurance. Where should I start?

    Choosing a plan that’s right for you doesn’t have to be hard. Before you look for a plan, ask yourself a few questions:

    • How much can I spend each month?
    • How often will I visit the doctor?
    • How many prescriptions do I fill each year?

    If you can answer these questions, you can find a plan that’s right for you.

  • There are so many plans. What's the difference in cost?

    Here are a few things to think about when trying to figure out the total cost:

    • Copay – the amount you pay for covered services, like doctor visits and prescription medicines.
    • Annual deductible – the amount you pay out-of-pocket each plan year before your plan starts to pay.
    • Annual out-of-pocket maximum – the most that you will have to pay out-of-pocket during the plan year. This usually includes copays and your deductible.
  • How will I know how much I should be paying for my insurance?

    You’ll want to find a plan that works within your budget. When considering the total cost of your insurance, think about how your costs will add up over the year. Based on your own medical situation, you’ll want to look at different things in each plan:

    • Are you healthy? A plan with a lower premium may have a higher deductible, and higher copays for prescription drugs or doctor visits. Generally, people who choose plans with a higher deductible file fewer claims. But it’s good to keep in mind that choosing a plan with higher deductible will also mean you’d pay a higher out-of-pocket cost, if you do file a claim. If you don’t go to the doctor often or you don’t take prescription medicines regularly, you could save money. A plan with a lower premium can save you money each month, but if you need medical help, you may pay more out-of-pocket.
    • Do you expect to go to the doctor often? If you have a condition like high blood pressure or diabetes, you will probably visit your doctor a few times a year to track progress. You may want a plan with a higher premium and a lower deductible, as well as lower out-of-pocket expenses, like copays or coinsurance. That way, you’ll pay less when you visit the doctor.
  • I need to take medicine on an ongoing basis. Is there a way to see if my medicine is covered?

    As you shop for a health plan, check whether or not any medicine you’re taking now is on the plan’s drug list, or formulary, and see how much it will cost. Sometimes a plan with a higher deductible will have slightly lower medicine costs – so you may save money over the year. If your medicine isn’t on the drug list, ask your doctor about other medicines you could take instead, that are covered.

  • The plan I'm looking at says I have a four-tier formulary. What does that mean?

    Usually, a plan will have different tiers, or levels of coverage for medicines. You may see plans with one to four tiers. Generally, the lower the tier, the lower the cost of the medicine. Here’s an example of how a four-tier plan might list medicines:

    • Tier 1 drugs – the lowest-cost, mostly generic drugs.
    • Tier 2 drugs – medium-cost drugs, most are generic and some brand-name drugs.
    • Tier 3 drugs – high-cost drugs, mostly brand-name drugs.
    • Tier 4 drugs – the highest-cost drugs, mostly brand-name, newer drugs.
  • I see the letters PA, ST and QL by a plan selection. What do these letters mean?

    • PA stands for Prior Authorization. This means that your plan has to give authorization before it will help pay for certain medicines.
    • ST stands for Step Therapy. Some medicines may require step therapy – meaning, you may have to try a different medicine to treat your condition before your plan will cover the medicine your doctor first prescribed for you.
    • QL stands for Quantity Limits. Some medicines have quantity limits, which means that the pharmacy may only be allowed to give you exactly enough medicine to cover a certain period of time. Quantity limits are usually for very expensive medicines (so you don’t buy more than you need), or for medicines that are more likely to be overused or abused.
  • Can I get my medicine from the pharmacy down the street?

    Yes. When you sign up for a plan, there will be a list of pharmacies that are in your network. These pharmacies are usually able to offer covered products and services at lower rates. You can check to see if your local pharmacy is on that list. If your pharmacy isn’t on the list, or out-of-network, you will still be able to get your prescriptions filled there. But, medicines may cost you more since you are not using the network.

  • Who is covered?

    A member is someone who’s covered by a health care or pharmacy plan. You can be the only member on your plan, or if you have a family, anyone you bought coverage for is also a member. You may also see the word subscriber on some of the documents you review. A subscriber is the person who signed up for coverage.

  • What is a prescription drug plan?

    A prescription drug plan, or pharmacy plan, is a part of your health care coverage. Prescription medicines can be expensive. When you have pharmacy coverage – or prescription drug coverage – your pharmacy plan may pay a portion of the costs of prescriptions your doctor or other health care professionals prescribe for you. These medicines can be something you take for only a short while, like an antibiotic to treat an infection. They can also be something that you take for a longer time, like medicine to treat high blood pressure, or insulin to treat diabetes.

  • How does a pharmacy plan work?

    When you visit your doctor, he or she may prescribe medicine for you. Here’s how the plan works:

    • Take your prescription and member ID card to the pharmacy to get your medicine.
    • The pharmacist fills your prescription and checks with your pharmacy plan to see how much to charge you for your prescription.
    • Because you have a pharmacy plan, you may pay less for your medicine – the amount you pay is called your cost-share. Your pharmacy plan pays the rest.
    • Depending on how your health plan is designed, you may have to pay the full cost at the beginning of your plan year, until you meet your deductible. A deductible is the amount of money that you pay out-of-pocket for covered services, before your plan starts to pay.
  • How do I know what medicines are covered?

    Your pharmacy plan covers many different kinds of prescriptions medicines. You can see the exact medicines your plan covers by reading the drug list, or formulary. Your plan’s drug list will tell you what medicines are covered and which are not, including brand-name and generic medicines.

    Keep in mind that some medicines may be on your drug list, but they may not be covered for situations that aren't considered medically necessary. For instance, the medicine Retin-A (tretinoin) treats acne in people under age 21, but a doctor may prescribe it for cosmetic purposes. Check your plans’ Evidence of Coverage or Certificate of coverage document to learn more.

  • What's the difference between brand-name and generic medicines?

    • Brand-name medicines are sold by a pharmaceutical company that has the patent, or license, on a particular medicine. You may see ads for these medicines on TV and in magazines.
    • Generic drugs have the same active ingredients as brand-name drugs, but they can be manufactured and sold by other companies, after the patent (license) has run out on the brand-name drug. The Food and Drug Administration requires these drugs to work the same as the brand-name versions.
  • How do I get my medicines?

    • Once you have your prescription, you can go to any pharmacy to have it filled.
    • A network pharmacy works with your prescription drug plan to fill prescriptions, usually at a lower cost than an out-of-network pharmacy.
    • Pharmacy networks are usually large enough to give you many pharmacy choices.
    • Networks include major chain pharmacies and local independent pharmacies. It’s your plan’s way of keeping costs lower to keep your cost of coverage as affordable as possible.
    • You may also be able to use your pharmacy plan’s home delivery option. This is a great option if you take a maintenance medicine for a condition like high blood pressure, asthma or diabetes, and take your drugs for long periods of time. With home delivery pharmacy, you can get up to a three-month supply of your medicine delivered right to your home.
  • How much money can I save?

    It depends on the plan you choose. When you’re looking for a plan, check to see what is included for the price you pay.

    • Some plans have a higher premium, but your deductible may be lower and your plan may pay more of your medical or prescription drug costs.
    • Other plans might have a lower premium, but you may have a higher deductible and pay more for your prescription drugs or doctors’ visits.

    Examples – why is the pharmacy benefit important?

    1) Meet Joe

    Joe is a healthy guy. He hardly ever gets sick, so he doesn’t go to the doctor often. Joe’s active and likes to ride his bike. One day last spring, Joe hit a pothole and crashed. After visiting the hospital and getting x-rays, Joe learned he broke his arm, and needed surgery to fix it.

    After surgery, Joe’s doctor prescribed a medicine to help manage the pain, along with an antibiotic. Joe’s prescription drug plan helped save him money:

    Joe’s pain medicine*:

    Drug Name Total cost: $200.00
      Joe’s copay
    (Joe has a 25% copay)
    $50.00
      Joe's plan paid: $150.00
      Joe saved: $150.00

     

    Joe's antibiotic*:

    Drug Name Total cost: $300.00
      Joe’s copay
    (Joe has a 25% copay)
    $75.00
      Joe's plan paid: $225.00
      Joe saved: $225.00
    Total saved on both medicines:   $375.00

     

    Because Joe’s prescription drug plan paid for most of the cost of his pain and antibiotic medicines, Joe saved almost $400 on the cost of those two drugs. Joe’s prescription drug plan paid for most of the cost of his pain and antibiotic medicines, Joe saved almost $400 on the cost of those two drugs.

    2) Meet Steve

    Steve just learned he has diabetes. He’s talked with his doctor, and treatment is going well. He’s exercising more and watching what he eats. He’s already slimmed down.

    To control his condition, Steve has to take medicine every day and check his blood sugar regularly. Thanks to Steve’s pharmacy coverage plan, he’s able to get the medicine he needs to stay well:

    Steve's diabetes medicine*:

    Drug Name Cost per month: $100.00 Cost per year: $1,200
      Steve's copay
    (Steve has a 25% copay)
    $25.00 Yearly copay: $300
      Steve's plan paid: $75.00 Yearly plan payment: $900
      Steve saved: $75.00 Yearly savings: $900

     

     

    Steve could choose to fill the prescription for his diabetes medicine through his plan’s home delivery pharmacy option. Not only can he get a 3-month supply of his medicine mailed straight to his house, he can even get a discount:

     

    Drug Name Cost for 3-month supply: $250.00 Cost per year: $1,000
      Steve's copay
    (Steve has a 25% copay)
    $62.50 Yearly copay: $250
      Steve's plan paid: $187.50 Yearly plan payment: $750
      Steve saved: $187.50 Yearly savings: $750

    *Numbers used here are for illustration only – your actual drug costs might be different, based on the drugs you are prescribed and your plan design.

  • What happens when I give my pharmacist my prescription?

    • The pharmacist uses the number on your ID card to check the details of your plan. This way, the pharmacy can check to see if your plan covers the drug you were prescribed, based on your plan’s formulary, or drug list.
    • They learn what your copay or cost share amount will be. This is the amount of money that you pay out-of-pocket for your prescription medicine.
    • If your prescription is for a brand-name drug, they find out if you could save money by using generic drugs instead of brand-name drugs. A generic drug has the same active ingredients as a brand-name drug, and is put on the market when the patent for the brand-name drug runs out. Using generic drugs can save you money.
  • What's the difference between a pharmacy that is in my network and one that is out-of-network?

    Your pharmacy plan works with pharmacies all across the country to create a network. A network is a large group of pharmacies that have contracts with an insurance plan to offer covered products and services at a lower rate to insurance plan members.

    • Pharmacy networks are usually very large and include major chain pharmacies as well as local independent pharmacies.
    • You can also use an out-of-network pharmacy, but your plan might not pay for your prescriptions. This means your medicine may cost you more. In some cases, your plan might pay for part of your prescription, but you would have to file a claim for reimbursement.
  • What is a home delivery pharmacy?

    Home delivery pharmacy is an option if you take long-term medicines for conditions like high blood pressure, asthma or diabetes. Using home delivery pharmacy, you can get up to a three-month supply of your medicine delivered right to your home. Home delivery pharmacies can save you time and money. Check the details of your plan to find out more about home delivery pharmacy. Some plans require you to get your long-term medicines through home delivery pharmacy in order to have some of the cost covered. A home delivery pharmacy is also called a mail order pharmacy.

    Examples – how does your pharmacy benefit work?

    Meet Susie

    Susie has asthma. Her doctor gives her a prescription and she takes it to her pharmacy to be filled. Because Susie’s health plan includes pharmacy coverage, she gets help paying for her prescription medicines. Susie’s drug store is in her pharmacy plan's network. She may be saving some money just by using a network pharmacy.

    Susie’s asthma medicine* from a retail pharmacy:

    Drug Name Retail cost per month: $200.00 Cost per year: $2400
      Network price $160.00 Cost per year: $1920
      Susie’s copay
    (Susie has a 25% copay)
    $40.00 Yearly copay: $480
      Susie's plan paid: $120.00 Yearly plan payment: $1440
      Susie's total savings: $160.00 Yearly savings: $1920

     

    Susie decides to fill the prescription for that same asthma medicine from a home delivery pharmacy instead of her local retail pharmacy. She get a 3-month supply of her medicine mailed to her home and she can get a discount:

     

    Drug Name Cost for 3-month supply: $250.00 Cost per year: $1000
      Susie’s copay
    (Susie has a 25% copay)
    $62.50 Yearly copay: $250
      Susie's plan paid: $187.50    
      Susie's total savings: $187.50 Yearly savings: $750
    Yearly savings over retail: $2,150    

    With the home delivery option, Susie saves $230 each year compared to using a retail pharmacy, and she doesn’t have to make a trip to the pharmacy every month to get her medicine. She saves more than $2100 each year compared to not having pharmacy coverage at all.

    *Numbers used here are for illustration only – your actual drug costs might be different, based on the drugs you are prescribed and your plan design.