What’s Covered? What’s the Cost?
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Your Plan's Formulary
A formulary is a list of prescription medications that are covered and approved by your Healthfirst plan. We only pay for the medications (brand or generic) that are on this list, unless your doctor contacts us to get an exception and receives approval.
For some prescription medications, your doctor may need to get prior authorization from us before it’s approved for you to pick up at your pharmacy. If your doctor doesn’t get approval from us first, then we may not cover the medication, and the prescription may not be available when you go to pick it up.
To avoid this situation, your doctor should understand which medications need prior authorization and reach out to Healthfirst for approval before giving you a prescription for that medication.
If you have any concerns about medications that may need prior authorization, talk to your doctor.
You can check to see if your medications are on your plan’s formulary and whether they need prior authorization here.
Keep in mind that though your medications may be on your plan’s formulary, it doesn’t necessarily mean you won’t have any out-of-pocket costs. Depending on your plan, your deductible, drug tiers, and other factors, you may have to pay a portion of the cost.
Deductibles and other Cost Factors
Depending on your plan, you may have an annual drug deductible. If you do, then at first you would pay the full amount of your prescription medication until you have reached your deductible amount. Then we’ll pay for either the full cost of the medication or a portion of it, depending on your plan.
If you’re a Medicare Advantage member with Part D Prescription Drug Coverage, there are a few factors that affect your drug cost. See below.
With Part D benefits, there are four stages of coverage throughout your benefit year, in the following order:
COVERAGE GAP (DONUT HOLE)
The stage that you’re in partly determines what your out-of-pocket cost will be. Advancing to the next stage is determined by how much you and your plan have paid for your prescription drugs so far. As you get to each stage’s spending limit, you move to the next stage and your drug costs will change. Spending limits for each stage may vary by plan.
Important! During Stage 1 (Annual Deductible) and also during Stage 3 (Coverage Gap), depending on your plan and your type of prescription drugs, you may pay more out of your pocket. This is because in Stage 1 you must first reach your drug deductible (if you have one) before your plan starts to cover more of the cost in Stage 2 (Initial Coverage). When your limit for Initial Coverage is reached you advance to Stage 3 (Coverage Gap), where you would pay more for your drugs, until that limit is reached.
Not everyone gets to Stage 3 or Stage 4. If you do advance to Stage 4 (Catastrophic Coverage), your plan typically pays almost all of the cost of your drugs.
Further, if you qualify for Extra Help (a low-income subsidy program) you’re unlikely to experience all of these stages, and your out-of-pocket costs would be lower. More information on Extra Help is available in the “Help with Costs” section.
Note: These stages are created by the Centers for Medicare & Medicaid Services (CMS).
Medication (Drug) Tiers
Another factor that impacts your cost is the tier that your prescription medication is in.
Prescription drugs are grouped into different levels called “tiers”. Depending on your plan, there may be Tier 1, Tier 2, Tier 3, Tier 4, Tier 5, or more tiers.
Generally, the higher the tier, the more expensive the medication would be, and there would be more out-of-pocket costs for you. This is because Tier 1 and Tier 2 typically contain mostly generic drugs, which cost less. As you go up in tiers, those contain brand-name and specialty drugs, so those cost more. You can check your plan’s formulary to see what tier your medication is in.
We understand that figuring out drug costs can be challenging. You can always contact us to help you better understand your costs.