Prescription Coverage 101

Bill Mally, R.Ph. - Barberton Location

Q: I am confused by the term "formulary" that is used frequently in my health plan regarding prescription coverage. What is it?

A: Drug formulary refers to the list of prescription medications or pharmaceutical products developed and approved by each health plan to encourage greater efficiency in the dispensing of prescription drugs without sacrificing quality. The list will contain both generic and brand name drugs selected for coverage under a health insurance plan.

Drugs named in the formulary are further classified as preferred or non-preferred, or tier 1, 2, 3, etc. Both of these determine the out-of-pocket cost, or co-pay, the patient is responsible for when prescriptions are dispensed by participating pharmacies such as Ritzmans. Drugs are included in the formulary list on the basis of their efficacy, safety, and cost-effectiveness. Drugs that are not on the formulary list are considered "non-formulary" items. Sometimes, coverage for non-formulary drugs is given only after the physician obtains prior authorization through the insurance company. If you have questions about your prescription drug coverage you should contact your health plan by calling the number on your prescription card. The pharmacists and staff at Ritzmans will work with your doctor and insurance company to provide the medications you need at the least cost to you.


Q: My health insurance plan gives me a phone number and an e-mail address to receive my prescriptions by mail. Do I have to order my prescriptions by mail or can I still go to my local pharmacy?

A: Many health insurance plans offer a prescription mail order service as an option for its members. Others mandate that members use mail order or may strongly suggest mail order. At Ritzman we believe in the value of interacting with your pharmacist on a personal level - eye to eye, being able to explain your medications and answer your questions. If you feel your insurance is insisting you use mail order, talk to a Ritzman pharmacist or associate, we may be able to help you retain your right to get your prescriptions filled locally.


Q: My health insurance plan requires me to pay a $15 co-pay for prescriptions. Will my co-pay be the same no matter what pharmacy I go to?

A: If your insurance plan requires straight co-pays for prescriptions, for example, a $5 co-pay for a generic drug, and a $15 co-pay for a brand name drug, your co-pay will be the same no matter what pharmacy you have your prescription filled at. However, there are some prescription drug plans that use a "percentage-of-cost" instead of a straight co-pay structure. This means the patient is responsible for a percent of the total cost of the medication, which can vary from pharmacy to pharmacy.