Top Benefit Plan Questions

Employees who are knowledgeable about their health benefit plan can make better decisions for themselves and their families.

The following frequently asked questions provide important information on drug plan coverage:

  • Will all prescriptions be covered by my insurance plan?
    • You may not know whether a medication you or a family member may need is covered by your private insurance plan. If you have a chronic condition for example, you should know about whether your prescribed medicine is covered. Every insurance provider has a formulary or list of medicines covered by the plan. If the prescribed medicine is not listed on the formulary, you may be required to jump through a lot of hoops to get coverage or pay out of pocket. Read the fine print and talk to your benefits manager about your options and concerns.

  • What are my out of pocket costs?
    • There are a number of costs plan members must bear as part of their drug plan, including monthly premiums typically deducted from your pay or deductibles. At the time of dispensing, there can be other costs including deductibles, co-pays or other spending limits on a particular drug or an overall drug spending cap.

      The amount of out-of-pocket expenses will vary based on your coverage. Check with your insurer to understand how much you’ll have to pay before your employer plan covers your medicines.

  • If my doctor prescribes a brand name drug, why do I get the generic version at the pharmacy? Do I have the right to ask for a brand name medicine if it has been prescribed by my physician?
    • Choice is an important consideration in ensuring patients have access to timely medication. Different plans have different rules about substituting innovative drugs for generic drugs. Some plans are known as “mandatory generic” which means a brand name medicine will be automatically substituted for a generic version. This means you must either accept the generic or pay the difference in the price between brand and generic.

      Your physician may prescribe a brand name medicine which is covered by your plan, but will be substituted for a generic when the prescription is filled at the pharmacy. In this case you can insist on the brand name and your physician may write “no substitutions” on the prescription – however, whether your insurance covers the full brand name price will depend on whether your plan has a “mandatory substitution” reimbursement rule.

      You should discuss these issues with your employer/insurer, your pharmacist, and your physician to determine your options.

  • Are there rules or policies that restrict or delay access to medications for me or a member of my family?
    • Health plans may require plan members to take additional steps before medications are covered. This can lead to delays in treatment and increased frustration. As insurers move to more managed drug plan models, programs like prior authorization, step therapy, managed formularies and case management are being implemented. These requirements often involve additional steps for physicians and other practitioners as well as patients.

      You may hear decisions to cover or exclude certain medicines from the formulary are based on “cost effectiveness.” However, there may be little evidence to show how a certain medication is working in comparison to another in its therapeutic class. Often times, the lowest cost medicine is more expensive in the long run if the treatment is less effective and leads to increased absenteeism or other complicating factors.

  • What can I do to minimize restrictions and delays in accessing medications?
    • Ask your employer/insurer about restrictions and delays you might encounter based on the rules in your plan. Let your employer know ahead of time what drugs you anticipate, and arrange for forms and paperwork to be filled out ahead of time if possible.

      It is also important to communicate these restrictions with your physician. Restrictions to access in privately-covered employer plans are still new and your physician may not be familiar with this concept, or with the restrictions in your particular plan. Communicating these restrictions will allow your physician to know which medication to prescribe and in what order, as well as what paperwork to fill out, to ensure your medications are accessible in a timely fashion.


If you would like to know more about your plan, speak to your human resources or benefits plan advisor.