Understanding Insurance


Does your insurance pay for medications from Edgerton Pharmacy?

Check with us! We belong to a nationwide group of pharmacies that allows us to fill prescriptions for most prescription drug plans. Prescription drug plans change frequently and we want the opportunity to be your pharmacy of choice. In many cases, we can fill your medication at Edgerton Pharmacy for the same price you are paying at a chain pharmacy! Understanding prescription drug coverage can be confusing. Listed below are some common facts about prescription drug coverage to help you better understand your options. Need more information? Contact one of our pharmacy staff members.

What medications are covered by your prescription drug plan?

Not all prescription drug plans cover all drugs, and if you need a drug that’s not covered, it can send your out-of-pocket costs through the roof. Health insurance companies publish lists of the prescription drugs they cover, and this list is called a formulary. A drug formulary is a list of all the drugs covered by the prescription drug plan. Some drugs may be covered automatically with a doctor’s prescription. Others may be covered only for treatment of specific conditions or after you’ve tried a different, preferred drug first. You can usually get the most recent copy of your prescription drug plan’s formulary by calling your insurer or visiting their website. Before committing to a plan, you should look at the formulary to see if your drugs are covered.

What are drug coverage tiers and how do they work?

If your health insurance plan utilizes drug coverage tiers, it can affect how much you pay for prescriptions. Drug coverage tiers are a means of categorizing different kinds of drugs and encouraging patients to use more cost-effective options when possible. Drugs from higher tiers may cost you more out of pocket than drugs from lower tiers.

  • For example, a health insurance company may categorize drugs into four different tiers:
  • -Tier 1 may include only generic drugs and may only cost you a minimal copay.
  • -Tier 2 may include preferred brand-name drugs. Your copay for these drugs may be higher than your copay for tier 1 drugs.
  • -Tier 3 may be comprised of non-preferred brand-name drugs. Expect to pay a still-higher copay for these.
  • -Tier 4 may include what are called specialty drugs. These are drugs that are costly and associated with treatment for rare or serious medical conditions. Tier 4 drugs may cost you more out of pocket than even tier 3 drugs.

How much will you pay for medications?

The answer to this question will vary based on the kind of coverage you have. But when it comes to drug coverage, health plans typically break down into three main groups.

  • GROUP 1 – Drug coverage before your deductible
  • -If your plan covers your drugs before you meet your deductible, each drug will be subject copays or coinsurance. Your out-of-pocket costs will vary depending on the drugs you take.
  • GROUP 2 – Drug coverage after your deductible
  • -Some plans do not cover the cost of prescription drugs until you meet your plan’s annual deductible. Pay careful attention to plans that require you to fulfill a deductible before drug coverage kicks in.
  • GROUP 3 – Drug coverage after a special prescription drug deductible
  • -Some plans may have special deductibles solely for prescription drugs. These deductibles are separate than your overall deductible for medical care. Once you’ve paid out your prescription deductible your drugs may be covered with a copay.

Remember, no matter which category your plan falls into, some drugs may not be covered at all, or only in certain circumstances.