How much do you know about the ins and outs of your prescription medications and pharmacy benefits? Chances are some of the fine print seems mysterious.
A little know-how can save you money on your prescriptions and guide you to clearer conversations with your doctor and pharmacist. Start with these six terms:
1. What’s a drug list, and what are tiers?
A drug list (sometimes called a formulary) describes which medications your health plan covers and how you share in the cost. A group of medication experts continually reviews the list to make safe, effective prescription drugs available to health plan members at the best value. Drug lists break drugs into groups called tiers. Each tier has a certain payment level. The specific tiers vary by health plan, but yours may look something like:
- Tier 1: mainly generics and some brand-names; lowest cost
- Tier 2: mix of generic and brand-name medications that provide good overall value; mid-range cost
- Tier 3: mostly brand-name drugs; highest cost
2. Why is there a cost difference between generic and brand-name drugs?
Brand-name drugs may have a higher price tag while companies recoup their development costs. A generic version of a drug has the same active ingredients and uses as the brand-name version, often at a lower price, but not always. It’s best to check with your doctor – some are able to electronically view their patient’s specific drug list and cost information.
3. What are maintenance drugs?
Maintenance medications are prescribed to treat chronic or long-term conditions and are taken on a regular basis. They include medications for high blood pressure, diabetes or high cholesterol. You may save money (and avoid running out) by ordering a 90-day supply for home delivery.
4. What does DAW mean?
The abbreviation DAW on your prescription means “dispense as written.” It’s an instruction to the pharmacist not to substitute the generic medicine for the brand-name drug. If you’re paying a brand-name price, ask your doctor to periodically review your prescription for more cost-effective options.
5. What’s preauthorization, and why do I need it?
Also called prior authorization, this term means your doctor needs to explain to your health plan why you need a specific drug. Without preauthorization, the drug may not be covered.
6. Why is my medication a controlled substance?
While most prescription drugs are non-controlled drugs, like blood pressure medications, asthma inhalers and antibiotics, from time to time you may have a need for a drug that is considered a controlled substance. These are medications that can cause physical and mental dependence, and therefore have restrictions on how they can be filled and refilled. The Federal Drug Enforcement Administration (DEA) rates drugs that have a high potential for misuse or risk as Schedule I, II, III, IV
or V:
Schedule I drugs are generally illegal drugs with no accepted medical use.
Schedule II drugs have high potential for abuse or severe dependence. Schedule II includes narcotics and opioids like morphine and oxycodone and ADHD stimulants like Adderall® and Ritalin®.
Schedule III, IV and V drugs have lower risks of abuse or dependence. They include narcotics with lower amounts of codeine, including cough medicine, and medications like diazepam (Valium®).[1]
The language in your health plan’s pharmacy benefit can be bewildering, but fortunately, you can get help when you need it. You can always contact your plan’s customer service representatives for an explanation, or ask your doctor or pharmacist. All of them want you to understand – and make the most of – your coverage.