Prescription drug plans are part of all commercial and government insurance plans in the United States; however, each plan is different per corporation / organization and state. When starting to understand your coverage you should immediately get familiar with your plan’s prescription drug list known as a PDL. This list will not only list what medications will be covered under your plan (called a formulary), but what category or “tier” each of these medications are listed into. Tiers represent a cost level. There are 4 tiers to a formulary list, tier 1 being the lowest cost and tier 4 being the highest cost. Tiers 1 – 3 usually require some co-pay, and it is not uncommon to have your co–pay cost listed on your pharmacy drug card. Most of these medications are generic, and brand name medications are often higher up on the tier list. If you have Medicaid or Medicare, it is not uncommon for your insurance to cover brand names. Some states have restrictions on how many brand-named drugs you can use per month (this included antibiotics). Tier 4, also known as the “specialty tier,” is where most specialty medications for rare diseases and new epilepsy medications are found.

Cost-sharing is the major difference between the specialty tier and those preceding it. While for lower tier medications you’d typically be charged a flat copayment for your prescription, specialty tier medicines usually come with a coinsurance payment. Coinsurance is a percentage-based rate – so if your coinsurance payment rate is 20%, you’ll find yourself paying for 20% of the medication’s overall retail cost. Because some medications can cost several thousands of dollars per month, you may end up meeting your insurance deductible very quickly just on coinsurance payments alone. Once you’ve met your annual deductible, insurers usually begin covering more (up to 80%-100%) of medication costs.

This is why it is very important to understand what your deductible plan is. Because each year in January, your progress toward “meeting your deductible” (i.e., the amount of money you spend each year) resets.

Many people utilize copay assistance cards so medications can be affordable; however, under the current copay accumulator programs, this can end up costing you more money in the long run. The TSC Alliance is advocating for co-pay accumulator programs to be removed. For more information on prescription process, including quick videos on these important topics check out the Alliance for Patient Access (AfPA) who advocate for patient access to approved therapies and appropriate clinical care.

Another important aspect of pharmacy coverage is step therapy. This is also called “fail first” policy that was developed by insurers to help control cost. This means some plans require you to try cheaper and outdated drugs FIRST before they will cover a specific drug prescribed by your healthcare provider. This is a very frustrating process and can be risky for those with a rare disease and epilepsy. As you are understanding your pharmacy benefits, pay attention and ask which medications require step therapy. It is equally important to understand that many other advocacy groups have taken a proactive stance on getting step therapy legislation changed. Here is a great resource to find out if there is an override request available in your state, and what to do if your override request was denied.