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The “donut hole” (or coverage gap) is a gap in prescription drug coverage. It occurs after the total cost of your medications during the year has exceeded a certain amount. Call us to discuss any questions you may have about your personal situation.

Your plan might require prior authorization for certain prescription drugs. Before your plan covers one of these drugs, your provider will need to contact your insurance company and explain why it is medically necessary for you. If a medication requires prior authorization, it will be noted on your plan’s Formulary.

A quantity limit is a cap on how much of a medication you can get in a certain timeframe. Insurance companies place quantity limits on certain drugs for safety and cost reasons. If you are prescribed more than the quantity limit, your provider will need to contact the insurance company to confirm that the additional amount is medically necessary.

In some situations, certain vaccinations may be covered. However, most provider offices are unable to bill these claims to your prescription drug plan. Typically, most have an easier time obtaining coverage by getting vaccines from a pharmacy instead of a provider’s office. If you have questions about the specifics of your plan’s benefits, call our team.

Step therapy is a type of prior authorization required by an insurance company. Specifically, it is the process of treating a medical condition with the most cost-effective medication before progressing and providing coverage for a more costly medication.

A prescription drug deductible is the amount you must pay annually before you start paying the fixed copays as outlined by your plan. Not all Medicare plans have a prescription drug deductible. You can refer to your Summary of Benefits to determine your deductible and copay amounts.

Generally speaking, Part B covered medications include those given by a doctor in a medical office or hospital setting; they are determined medically necessary by a provider. Part D medications are generally maintenance medications that you take yourself (the type you pick up from the pharmacy). Please visit Medicare’s website to learn more.

If you are having trouble paying for medication costs, you may have options. If the medication is not listed on your formulary, it is possible for your provider to request a formulary exception from the insurance company by providing medical necessity. Another option is to contact the Social Security Office to determine your eligibility for a federal program called Extra Help. For more tips on how to save on medication costs, watch this video. If you would like assistance or have further questions, contact our team.

During a hospital visit, any routine prescriptions you need that are given by the hospital are considered self-administered drugs. These medications are typically not covered in your hospital co-pay, unless they are required for the hospital services you are getting. You will most likely be billed for the full amount. Once you have paid your bill, you are able to request reimbursement from the Part D portion of your plan through a form called a Prescription Drug Reimbursement Claim Form. We recommend that you check the hospital’s policy on bringing in your own medications, which may allow you to avoid these types of bills. If you find yourself in this situation, contact our team to learn more.