How are prescription copayments determined?
Insurance plans determine prescription copayments. Copayment amounts can differ based on the specific medications needed.
What is a prescription copayment?
Prescription copayments are the amount of money you are required to pay out-of-pocket for a medication. Your insurance plan pays for a certain amount of medication. What is left over is the copayment you are required to pay out-of-pocket.
Not all insurance plans require prescription copayments, so it is possible you may not have them.
What can affect my out-of-pocket costs?
There are a few things that can affect how much you are paying for your medications:
Every insurance plan is different. It’s important to understand the following:
- Deductibles. If your insurance plan has a deductible, you are required to pay the entire medication cost until you have paid enough to meet that deductible. Once you have met your deductible, your insurance benefits will begin. This means you will now pay a smaller amount, which is called your copayment.
- Preferred pharmacies by your insurance. Your copayment can be lower if your pharmacy is “preferred” by your insurance plan. Your copayments can be higher by going to non-preferred pharmacies. Your insurance plan can provide you with their list of preferred pharmacies.
- Copayment tiers. Most prescription insurance benefits have different levels for medication copayment costs. These are called copayment tiers. In this case, your copayment is determined by the tier of the medication. Here is an example of what this can look like:
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- Example Tier 1: Generic medications require a $0 copayment from you.
- Example Tier 2: Generic medications require a $5 copayment from you.
- Example Tier 3: Brand-name medications require a $20 copayment from you.
- Example Tier 4: Brand-name medications require a $45 copayment from you.
* The tiers described here are examples only. Your insurance determines what medications are in each tier. Check your insurance plan description for details on how your copayment tiers are structured.
- Medications that are not covered. Some medications are not paid for by your insurance plan. If this happens, you are required to pay the full amount for these medications. Some insurance may not cover over-the-counter medications without a prescription.
- Brand-name medications. Brand-name medications can be more expensive than the generic version. This doesn’t mean that generic medications are less effective. Generic and brand-name medications have the same active ingredients. Both go through thorough reviews by the Food and Drug Administration (FDA).
Check out this helpful FDA article for answers to other questions you might have about brand-name and generic medications.
What if my medication copayments are too expensive?
Talk to your insurance plan, doctor, or pharmacist if you can’t afford your medications. They can help you find alternatives to save money while keeping you healthy. Sometimes they can find cheaper medications.
There are other options to help you lower or eliminate your prescription copayments:
- Medicare Part D Extra Help Program. Medicare offers a program to help lower medication expenses for individuals. You can click here to check if you are eligible or to apply.
- Coupon cards. Employer-sponsored health insurance plans allow manufacturer coupon cards to be used to lower the out-of-pocket price. Medicare and Medicaid plans do not allow these coupon cards to be used with your pharmacy benefits.
If you are an ExactCare patient and have questions about your copayments or medication, call us at 1-877-355-7225. Our staff is here to help!
- Center for Drug Evaluation and Research. (n.d.). OGD research to better understand patient perceptions of generic drugs. U.S. Food and Drug Administration. https://www.fda.gov/drugs/news-events-human-drugs/improving-medication-adherence-and-patient-experience-researching-patient-perceptions-generic-drugs
- Sciences, N. A. of, Engineering, & Medicine, and. (2017, November 30). Factors influencing affordability. Making Medicines Affordable: A National Imperative. https://www.ncbi.nlm.nih.gov/books/NBK493090/
