Understanding your health care plan's rules on prescription drugs

One goal you may want to set this year is to understand your health plan rules, especially those for prescription medicines. Even if you didn't change health plans, your plan's rules may change at any time and in ways that impact your access to medicines and how much you'll have to pay for them.

While most people have a sense of how to use their insurance for doctor's visits, many overlook the benefits that cover prescription medicines. These benefits can work differently and have different rules than those for office visits. This may become a problem when you go to the pharmacy to pick up a new prescription and find that you're having a hard time getting your plan to pay for it.

"A conversation with your pharmacist about the medications you take can be an invaluable resource in making the best use of your health insurance plan's prescription drug coverage," said Bruce Roberts, R.Ph., executive vice president and CEO of the National Community Pharmacists Association.

A new Web resource, called www.YourPharmacyBenefit.org, helps consumers troubleshoot common problems, including situations where:

• The information your pharmacy has about your plan doesn't match what is on your pharmacy benefit ID card.

• It's too early to refill the prescription.

• A particular medication may react badly with another medication you're on or with another medical condition you have.

• The medicine your doctor prescribed requires your plan's approval.

• The medication is not covered by your health plan, or is not on the "formulary," the list of medicines covered.

The Web resource explains all of these situations and provides tips on how to deal with these problems, how to translate "insurance-speak," and who to contact when questions arise. It also explains how to file an appeal with your insurance company if the plan refuses to cover a medicine you need.

"Many consumers don't realize that they don't have to take a simple 'no' for an answer," says Bill McLin, executive director of the Asthma and Allergy Foundation of America. "Asking the right questions may reveal that the problem isn't difficult to fix. It's smart to know how to navigate your insurance plan's rules so you can deal with coverage problems."

With the right information in hand, you can be sure you're getting the full value of your health coverage and that you receive the benefits to which you are entitled. For more information, go to www.YourPharmacyBenefit.org.

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