Understanding Your Prescription Drug Coverage

To manage costs, insurance companies create a list of medications that are covered on your plan. This list is known as a formulary, and generally includes generic and brand name drugs available with your coverage.

Once a formulary is created, it’s then divided into categories to help break down the cost of each covered drug. These categories are called drug tiers. Each drug is placed into a tier, which ultimately determines how much coverage is provided for each medication. The higher the tier, the less coverage and the higher your out-of-pocket costs will be.

Generic drugs, for example, often fall into the lowest drug tiers with the lowest out-of-pocket costs. The higher tiers generally contain specialty drugs that are needed for complex or rare diseases.

So, to help keep costs more affordable for members, Florida Blue covers most generic drugs. There may be instances where both a generic and brand version of a drug exists. In these cases, while the two drugs are created to be the same in dosage, safety, strength, quality, and more, the cost of the two drugs may vary greatly. Using tiers helps members understand which medications are less expensive.

It’s a good idea to check your pharmacy coverage from time to time as the formulary, a list of covered drugs, can change. This is especially important if your doctor recently prescribed a new medication. There are a few different options for how you can review your plan and find the pharmacy information you need.

1. Member website. Log in to your member account at floridablue.com and get access to your plan benefits, including pharmacy coverage. Once logged in, click My Plan and then Pharmacy. There you’ll be able to see covered drugs, compare prescription prices, find a pharmacy near you and more. 
2. Mobile app. When you download the Florida Blue mobile app, you’ll be able to view your plan details, including pharmacy coverage, just as you would on the website. It’s your plan at your fingertips.
3. Member service. Need help navigating your account? Call the number on the back of your member ID card.

Some generic medications are considered “authorized” generics. This means that the drug has been produced by only one manufacturer. When this happens, it often increases the price of the drug, resulting in a generic medication that costs the same amount as the brand version. When more manufacturers produce a generic drug, it decreases the cost of the medication, making it more affordable and accessible.

There may be other occasions where the generic version of a drug isn’t covered because it’s not considered the most clinically effective treatment. In these instances, there are usually better options available to treat a given condition or disease.

If you’re considering switching any of your generic medications to brand versions, there are some important things to keep in mind. Generic drugs help keep costs more affordable for members. That means that if you choose the brand version of a drug when the generic version is covered, you could end up paying additional fees. In fact, most plans have a penalty that applies to your cost share if you elect to get the brand medication. If this happens, you’ll be required to pay the cost difference between the two medications, plus your co-pay.

For example: If your drug co-pay is $10 for generic and $40 for brand, and you choose a brand name drug when a generic is available, here is what you might pay. Difference in Drug Cost is $70 (Brand Drug Cost $120-Generic Drug Cost $50=$70) + Brand Co-Pay $40= $110 is Your Total Cost.

Almost all drug recalls are voluntary and precautionary based on the Food and Drug Administration’s (FDA) findings. The FDA inspects pharmaceutical manufacturing facilities worldwide to ensure the safety of these medications. This includes facilities that manufacture the active ingredients in the medications. Plus, generic medication is required to work the same and have the same active ingredients as their brand name counterparts in order to obtain FDA approval.

Check with the pharmacy first. This may happen if the drug recently had a generic drug become available. If so, ask the pharmacy to fill the generic version to help you save money. If the pharmacy doesn’t have the generic version, you can always check with another pharmacy to see if they have it in stock.

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