FOR INDIVIDUALS & FAMILIES
PBMP helps you understand prescription costs, make sense of coverage and explore what options may be available.
01
Explore potential ways to make your medication more affordable.
02
Understand the reason and what to ask next.
03
Get a clearer understanding of your benefits.
You don’t need to know the insurance terminology. Start with the question on your mind.
Find out what may be driving the price—and which questions are worth asking.
Prepare for a more useful conversation with your pharmacist, prescriber or health plan.
Ask your pharmacist to compare your insurance and cash prices. Check coverage with your plan, and ask your prescriber about appropriate alternatives. Assistance programs may be available; eligibility and savings vary.
Coverage does not always mean a low price. You may have a deductible to meet, a fixed copay or coinsurance based on a percentage of the cost. Ask your plan which rule applies and whether your pharmacy is in network.
Ask the pharmacy or insurer for the exact reason. Check whether the issue involves the covered-drug list or a prior authorization requirement. Your prescriber may need to provide information or request an exception. If coverage is denied, follow your plan’s appeal instructions and deadlines.
Prior authorization means your plan requires approval before it will cover certain prescriptions. Ask your prescriber and insurer what information is needed and who will submit it. Approval does not necessarily mean the prescription will be free.
Read the denial notice and ask your insurer to explain the reason and appeal process. Contact the provider if information needs correcting. Keep the notice and record the deadline. A medical claim denial and a rejected pharmacy transaction may require different next steps.
Some manufacturers and other assistance programs may offer help, depending on the medicine and your circumstances. Ask your pharmacist or prescriber about programs for your prescription and check the program’s current eligibility rules. No program covers every medicine or every person.
Check each plan’s covered-drug list, pharmacy network and coverage requirements. Compare estimated annual costs, including premiums, deductibles and prescription spending. The lowest monthly premium may not produce the lowest total cost.
Yes. Our explanations are written for individuals and families, including people helping a partner, parent or child understand prescription costs and coverage. For questions about a specific person’s plan, the insurer may need their permission to discuss it with you.
General education. Your plan confirms coverage; your prescriber guides treatment.
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