Prescription Medicines

This article discusses more express limitations and waiting period exceptions to coverage under our sample individual health insurance policy. These have to do with prescriptions.

Non-Participating Pharmacies

(Typical wording*):

Limitations, Exceptions and Non-Waiver (cont.)

A. Limitations and Waiting Periods (cont.) [In addition to the other general Policy limitations of coverage, the following specific limitations also apply]:

7. Insureds have the right to obtain Prescription Drugs from the pharmacy of their choice. However, if Insureds use a Non-Participating Pharmacy to fill their Prescriptions, then such Insureds must pay said pharmacy in full and file a claim form with the Company for reimbursement. In such event, the Insureds will be reimbursed by the Company at the discounted or negotiated rate for such Prescription Drugs that would have been paid to a Participating Pharmacy by the Company under this Policy if the Insured had used a Participating Pharmacy. The amounts applied under this section will be subject to the Separate Deductible for Non-Participating Providers and the Insured Coinsurance Percentage for Non-Participating Provider Services Subject to Separate Deductible for Non-Participating Providers.

 

"Prescription Drugs" are only those drugs and medications that by Federal law may only be legally obtained on an outpatient basis with a prescription.

A "Prescription" is the written authorization for a medically necessary prescription drug to be dispensed to an insured on an outpatient basis by a provider who is treating an injury or sickness.

The policy limits retail store-filled prescriptions to a single thirty (30) day supply for each new or refilled prescription drug unless adjusted based on the drug manufacturer's packaging size or based on supply limits. Mail order or home delivery filled prescriptions are limited to a single ninety (90) day supply for each new or refilled prescription drug.

If the deductibles and coinsurance limits don't apply, the benefit ultimately will be the same whether you use a participating or non-participating pharmacy. The only difference is you have to pay up front and then file a form for reimbursement if you use a non-participating pharmacy.

Failure to Present Proper I.D. Card to Pharmacist

(Typical wording*):

Limitations, Exclusions and Non-Waiver (cont.)

A. Limitations and Waiting Periods (cont.) [In addition to other Policy limitations of coverage, the following specific limitations also apply]:

8. Insureds who do not present their correct ID card at a Participating Pharmacy when their Prescriptions are filled must pay the pharmacy in full and file a claim form with the Company for reimbursement. In such event, the Insureds will be reimbursed by the Company at the discounted or negotiated rate for such Prescription Drugs that would have been paid to a Participating Pharmacy by the Company under this Policy if the Insured had used a Participating Pharmacy and properly presented their correct ID card at the time the Prescriptions were filled

 

  Here, again, you do not lose any benefit if you fail to present the correct ID card when asked. You just have to file a form for reimbursement with the company after you pay for the prescription in full.

Prescription Pre-Authorization table

(Typical wording*):

Limitations, Exclusions and Non-Waiver (cont.)

A. Limitations and Waiting Periods (cont.) [In addition to the other general Policy general limitations of coverage, the following specific limitations also apply]:

9. Pre-authorization may be required by the Company prior to the time that Prescriptions for certain Prescription Drugs are filled.

 

The company may require pre-authorization if your health care provider prescribed uncommon or experimental drugs. This is not unusual. In some cases, insurance companies reduce or deny benefits if the insured does not obtain pre-authorization when asked to do so. Pre-authorization allows the insurance company to keep closer tabs on how much is being spent on your treatment.

Prescriptions not Applicable to Deductible

(Typical wording*):

Limitations, Exceptions and Non-Waiver (cont.)

A. Limitations and Waiting Periods (cont.) [In addition to the other general Policy limitations of coverage, the following specific limitations also apply]:

10. Because the Calendar Year Deductible or the Separate Deductible for Non-Participating Providers under this Policy is calculated on the basis of Covered Expenses, it is possible that every dollar an Insured pays for Prescription Drugs at a Participating Pharmacy or a Non-Participating Pharmacy may not apply toward meeting the Calendar Year Deductible or the Separate Deductible for Non-Participating Providers.

 

Not all costs of prescription drugs are necessarily covered expenses as defined under the policy. Those that are not will not apply toward the deductibles.

Prescriptions Paid in Error

(Typical wording*):

Limitations, Exceptions and Non-Waiver (cont.)

A. Limitations and Waiting Periods (cont.) [In addition to the other general Policy limitations of coverage, the following specific limitations also apply]:

11. In no event will Covered Expenses applied to the Calendar Year Deductible or Separate Deductible for Non-Participating Providers or paid by Us exceed the actual amount of expense agreed to be accepted as payment in full by the Participating Pharmacy after the application of all applicable negotiated discounts.

 

If, somehow, the combined provisions of the policy result in the potential for more money to be paid to a participating pharmacy than that pharmacy agreed in advance to accept as full payment, this provision states that the pharmacy is not entitled to more than it bargained for.

(Typical wording*):

Limitations, Exceptions and Non-Waiver (cont.)

Limitations, and Waiting Periods (cont.) [In addition to the other general Policy limitations of coverage, the following specific limitations also apply]:

12. Expenses charged to an Insured for Prescription Drugs that are mistakenly applied by Us to the Calendar Year Deductible or Separate Deductible for Non-Participating Providers or erroneously paid by Us under the Outpatient Prescription Drug Benefit does not mean We have any liability for coverage or the payment of any other Benefits under the Policy for the illness, injury or condition that resulted in such expenses, and any such mistake and error by Us shall not constitute a waiver of or modification to any of the conditions, terms, definitions, limitations or exclusions contained in either the Policy or any exclusionary rider attached to the Policy.

 

If the company makes an error by paying benefits for prescription drugs that it shouldn't have or by applying a deductible that it wasn't supposed to apply, that does not mean that the company is responsible for covering treatment for that injury or illness if such treatment is limited or excluded in any way under the policy.

*Wording may vary from contract to contract and from state to state