Insurance Information for Pharmacy @ Park Nicollet

Pharmacy @ Park Nicollet can tell you if your purchase will be covered by your insurance and exactly what the cost will be. All pharmacies are connected electronically with insurance companies. A claim is sent and an answer received which will indicate if the drug will be covered and what your copayment will be.

Each insurance plan has a list of approved drugs (also called a formulary) that they will cover. Each plan is slightly different, usually resulting in having to send a claim to your insurance to determine if the claim will pay. You can check in advance to see if a drug is covered by calling your insurance company customer service line.

Insurance companies contract with pharmacies to fill prescriptions for their members at specified rates. Pharmacies electronically send claims to insurance companies. Then the insurance companies tell the pharmacies how much to collect as copayments.

An insurance company may reject a claim. Most common reasons why:

• drug is not covered.
• physician is not a provider for the plan.
• patient is requesting more medication too close to the date of the previous fill.
• wrong or outdated insurance information is being used.
• insurance has been terminated.
• pharmacy is not a provider for this plan.
• drug requires approval by the plan and usually requires information from the prescriber.

What questions should I ask when picking an insurance company for medications?

• Will there be any savings at this time, or am I protecting myself against possible future expenses? (To determine if you will see immediate savings, write down what you would pay for current medications if you had no insurance. Your pharmacy can look up prices for you if you are not sure what the cash price would be.)
• What would be the monthly payment for drug insurance?
• What amount will insurance cover, what will my co-payments be and are they a percent of the drug cost or are they a fixed amount?
• Are there different copays for brand vs. generic drugs?
• Is there a preferred vs. nonpreferred drug list (or formulary), and if so, do the copays differ?
• How many days' supply can I get for one copay?
• Will I be required to use a mail-order pharmacy?
• Does the plan have an open or closed formulary (an open formulary usually means most drugs are covered, while closed usually means a more restricted list of drugs)?

If you have gathered this information and require further help, ask your pharmacist.