Home >> If insurance covers a prescription drug, why am I paying more than my copay?
If insurance covers a prescription drug, why am I paying more than my copay?
I thought if insurance DID cover a drug the participant was responsible for their copay, if they didnt cover it the insured could pay for the drug outright or get a script for a drug they do cover....I had a drug filled that was $140. The insurance company covered the drug and paid part of it, I still owed $111.28 vs my $15.00 copay---why is that? If they covered it, why would I still be liable for more than my copay?! thanks :)
If it's "non-formulary" - not on the list of covered prescription drugs - it might not be covered at all, or might have a very, very small discount. That's pretty common with very, very new drugs.
Although most plans offer a "formulary" copay, and a "nonformulary" copay.
Amusingly enough, my thyroid medicine from Walgreens was costing me my prescription copay every month ($25), but when I went to Sam's Club with it, it was only $11. Not even the copay.
One thing you can do, is go back to the doc and ask them if there's something "older" in a generic, that's almost as good as the new one . . . get a list from Walmart of their $4 prescription drugs . . . see if you can get something that does the same thing there, for $4.
because it probably was not a generic drug and the script the doc gave you was probably not for generic drug.....your insurance company probably only pay for generic drugs if there is one available for what you need......
Insurance companies have all kinds of tricks up their sleeves.
1. If you get a brand drug, and there is a generic for it, they can charge you the difference between that and the copay.
2. If you get a prescription that is not in their formulary, even if it is the best drug for the ailment, they can charge you a higher rate.
3. If you get a prescription for some drugs that used to have a generic, but no longer does, and the brand is now the generic, they can still charge you the higher rate as if it were brand with a generic available.
Hey, there are reasons the only ones in the health care profession that are making a profit are the insurance companies.
Sounds like it wasn't a covered drug, or that it wasn't covered at the same level as your $15 copay (which is probably for generics or some limited list of drugs on their "formulary").
Also, maybe your copay levels changed to a percentage? This happened to us this year... we used to pay $10/$25/$40 depending on the type of drug. Now we pay $10/$25/percent of total.
I would go back to your plan documents (frequently found online at the insurer's website) and review what your coverage is.
Well because JUST BECAUSE!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!...
Depends on how your insurance works. Many have multiple levels of drug coverage in their formularies. Mine has generics, preferreds, and others in the formulary. For each, I have a different amount that I pay. In my husband's case, he pays the copay on generics and a percentage of any other prescriptions. So, nobody on here can give you a solid answer, but I'm sure the insurance company would help.
Simple answer, the drug is not covered on that plans certificate as a brand name, preferred or generic.
In other words, the drug the doctor gave you is not on the formulary list.
Work with your health care provider and see if there would be another drug that is just as effective to treat your medical condition. Appeal to the insurance company and see if the requested drug can be added to the formulary.
You probably have a Prescription deductible... It sounds like you're getting the insurance company discount; but your copay's not applying. Maybe its non-formulary... Maybe a deductible. Something's getting covered or discounted. Call your insurance...
Co pay can be any amount even up to 99% of the cost of the drug. Some companies vary the copay based upon their assessment of the drug, it's cost and the cost of generic equivalents.