Prescription Drugs:
Understanding Your California
Group Insurance Prescription
Benefits
A main category to consider
while choosing your employee
group insurance benefits is
prescription drugs. You should
be concerned with this issue: it
is not a minor thing.
Prescription drug treatment and
costs have escalated
dramatically over the last
decade as medical technology
leaps forward resulting in many
of the most modern treatments
for the most severe conditions
require medications of specialty
classification and hugely
increased cost to research,
manufacture and distribute.
Often times once your employee
who has a surgery or
hospitalization incident will
result in a long term treatment
or preventative measure
utilizing prescription drugs.
Prescriptions are letting us
live longer lives fighting off
cancer, high blood pressure,
cholesterol, and heart disease.
Prescriptions have become so
crucial to treatment and so
expensive some employees and
members are willing to obtain
them from out of the country
through unlicensed and
unauthorized sources. Run a
quick web search and you’ll find
online pharmacies in Canada and
Mexico selling across the
border. It is a risky and
illegal proposition. Most
importantly you need to know
what you are purchasing in your
health plan and what it will
cover when you get a
prescription from your doctor.
Example Here’s what a typical
prescription drug benefit looks
like: “$10G $25B $250 Brand
Deductible 50% Brand Non
Formulary ”
$10G $10G
stands for ‘Ten Dollar Co-Pay
Generic Drug Prescription’ This
means if your doctor prescribes
a medication filled through a
pharmacy your employees will pay
$10 and nothing further.
$25B $25B
stands for ‘Twenty Five Dollar
Co-Pay Brand Drug Prescription’
This means your employees will
pay $25 for a Brand Drug
prescribed which is listed on
the health carrier’s formulary
drug list. The formulary drug
list is the list of acceptable
or preferred medications which
are established as the
medication of choice for certain
conditions. Note: if your
doctor prescribes a brand
medication, and a generic
version is available the
California group health
insurance carrier will force the
employee to pay the difference
in the cost between the brand
and generic drug. This will
happen even if your doctor
writes you a special note or
‘dispense as written.’
$250 Brand Drug Deductible
When facing a
brand drug deductible the best
way to understand how it will
function out of your employee’s
pocket is to view a sample claim
example. If the medication
taken costs $400 for a 30 day
order, you would pay the first
$250 out of pocket (each year)
and then the Brand Drug Co-pay
of $25 in our sample. Then in
subsequent months you would just
have to pay the $25 co-pay.
50% Brand
Non-Formulary
50% Brand Non-Formulary would
mean a prescription written
which is a brand drug but not
listed on the health carrier’s
Brand Formulary list. In this
case our example you’d pay the
Brand drug deductible because
the benefit is a percentage, and
the 50% of the cost of the
prescription.
If you have questions about
finding the best plan for your
employee’s prescription needs
contact us regarding your Group
health questions so
we can run a plan analysis for
you to determine which plan and
California group health
insurance carrier will be most
suitable. You can also view our
section on other
services our health insurance
agency provides.
Other
important
resources:
California
Small Group
health quote
California
Small Group
online
doctor
listing
California
Group
Enrollment
and
Eligibility
Center
