Prescription Drugs – Transitioning to New Coverage

Changing health insurance providers can provide premium cost relief, but can also present challenges related to prescription drug coverage.  Each health insurance plan generally contracts with a pharmacy benefit manager (PBM) to facilitate prescription drug coverage.  When a change in health insurance coverage occurs, this usually means a change to the PBM, and correspondingly, how your prescription drugs are covered, or not.  Here are some tips to help navigate a change in health insurance and PBM –

1. If you or a covered dependent relies on a drug that requires PRIOR AUTHORIZATION by your plan (e.g., many expensive drugs), then you’ll need to obtain a new prior authorization through your new plan’s pharmacy benefit manager (PBM).
2. If you’re not sure of the formulary status of the drug(s) you and/or family members are taking, know that your new plan’s pharmacy formulary is likely different than your previous plan’s Rx formulary.  The Rx formulary determines the cost and copay/cost tier of each available drug.  Generally, you can check the status of your drug(s) on the Health Plan and/or PBM’s web portal, or by contacting Human Resources. If you’re taking a relatively low cost, generic drug, there’s more than likely very little if any change to the associated cost/tier.
3. Be sure to provide your pharmacist (and/or mail order source) with your new health insurance ID card at your first dispensing occurring on or after the start of the new plan year.  This will assure the proper identification numbers are accessed by your pharmacy allowing for a smooth transaction at the pharmacy or mail order source.
4. If your first attempt to fill a prescription drug results in a denial,  there are many reasons for a denial.   You have an appeal right that you can always fall back on, if necessary.  Your physician is your best advocate to work with your health plan/PBM on getting you the medication you need.
5. Keep in mind the various cost saving options available to you, pertaining to prescription drugs.  Some of these include –
   – https://www.goodrx.com/
   – https://costplusdrugs.com/
   – https://www.singlecare.com/
   – https://www.samsclub.com/pharmacy?xid=hdr:shop:health-wellness:pharmacy
   – https://www.walmart.com/cp/pharmacy/5431?povid=GlobalNav_rWeb_PharmacyHealthWellness_Pharmacy_Pharmacy_control
   – https://pharmacy.amazon.com/

   Sometimes these resources offer prescription drugs at a lower cost than what your health plan/PBM has negotiated.  Ask your pharmacist to help you access the LOWEST COST prescription drug option, including your health insurance/PBM and one or more of the above resources!

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