Helping Customers Understand Health Insurance at the Pharmacy

Helping patients understand how prescription drug coverage works will help save them money.

Interacting with, and helping, the public is one of the largest parts of any pharmacy tech's workday, whether it is in person, in a retail pharmacy or over the phone in a mail order pharmacy.

You might have all the right answers for questions about the medications you are dispensing - because all good pharmacy techs do - but how well can you answer the questions about health insurance coverage that patients are increasingly asking, as policies become more complicated? Need some tips and guidance? Then keep reading.

Why Has Health Insurance Become So Complicated at the Pharmacy?

Prescription Bottles in a row on white.

The average health insurance policy is often not that easy for consumers to understand fully. And it can become even more complicated when it comes to prescription drug coverage.

A formulary is a list of drugs covered by an insurance plan.

Each insurance policy issued in the US comes along with its own set of rules, regulations and requirements for medications to be covered. Each insurance company has a drug formulary, a list of drugs and medications it provides coverage for. As this is usually shared with patients in the form of literature with a lot of fine print and very technical sounding jargon, it's little wonder that most patients really don't quite know what their health insurance will and won't cover and why.

The result can be a lot of confusion when it comes to getting their prescriptions filled. And often the person left responsible for trying to clear up some of that confusion is the person on the 'front line': the pharmacy tech.

What Health Insurance Problems Do Pharmacy Techs Encounter Most?

Entering medication on computer

Because there are so many different health insurance policies - and so many rules - the issues that pharmacy techs encounter will vary, but these are some of the most common.

Non Covered Medications

Just because their physician wrote a prescription for a medication does not always mean that a patient's insurance company will pay for it, either in part or at all. As I mentioned earlier, insurance companies maintain an ongoing drug formulary, but few physicians have the time to read them all and will often have no idea themselves whether the patient's insurance will cover the medication they are prescribing.

Patients can, understandably, become very upset when they discover that the medication their doctor prescribed is not something that their health insurance policy will cover. It's then often left to the pharmacy tech to explain their options to them, which may include obtaining a pre authorization to override the denial, changing the medication to a similar one that will be covered or, as a last resort having the patient cover some (or all) of the costs of the medication themselves.

It takes a lot of patience to resolve these kinds of issues. It often involves dealing both with the doctor's office and the patient and sometimes neither may like the options presented to them.

Differing Co-Pays

Co-pays can be confusing for patients as well. Often pharmacy co-pays are tiered, and may change according to the medication being prescribed. That means that the co-pay a patient is responsible for on one visit to the pharmacy might be quite different at another if the medications - or even the quantities prescribed - are different. This can lead to confusion and upset, and it will usually be up to you, the pharmacy tech, to explain to the patient the reason for the change if the patient asks.

The Rx pay card uses a four-tier formulary





$20 copay

$40 copay

$60 copay

$100+ copay

Very low-cost drugs, mostly generics

Higher-cost generic drugs and low-cost brand name drugs.

Brand name drugs for which there is no generic.

Highest-cost drugs or specialty drugs like chemotherapy.

Prescription Denials

There are all kinds of reasons why a prescription may be denied for coverage. It may be because it's too soon to refill a certain medication, or that the amounts prescribed are in excess of what insurance will cover. It may be that the patient has missed a premium payment or that their insurance has expired altogether. Whatever the reason for the denial though the one thing that you can be almost assured of is that the patient will be embarrassed and upset.

It's then the pharmacy tech's job to explain the reason for the denial as clearly, and compassionately, as they can, and offer suggestions for remedying the situation.

Educating Yourself to Help Educate Patients

Patient at a drugstore

Most of the time the basic information you need to explain a prescription issue to a patient will be provided for you on the billing screens. What is often not offered though are any suggestions for solving the problem. For example, a certain medication may not be covered and the billing screen will tell you that, but it won't offer an alternative by name.

This is where your knowledge as a pharmacy tech can be invaluable. You know that there are a number of medications that are quite similar to one another and can, in many cases, be substituted for each other. When you call a doctor's office for help with a script you'll often find that staff ask you to recommend an alternative, and so being able to do that is helpful.

As no pharmacy tech, or pharmacist, can prescribe medications, it is always up to the doctor to make the final call. But if they can be given suggestions for alternatives that they can then consider - and research if necessary - most will truly appreciate the help and the issue is solved faster.

It would take years for a pharmacy tech to familiarize themselves with every health insurance company's policies. But most find that, as time goes on, they do begin to remember that X company will not cover Z medication or that Y medication is an acceptable substitute that can be suggested to the prescribed. And that knowledge is always going to be helpful to everyone involved.

Going the Extra Mile

How to Read a Formulary

How to read a formulary (drug list)  Infographic

There are lots of things a pharmacy tech can do to help patients better understand their health insurance and how it works at the pharmacy.  And when they do it creates a better experience for everyone, even in what can be an upsetting situation. By encouraging patients to take the time needed to better understand their health insurance as a whole you'll be helping to make them healthier, and making that important contribution to their well being that make the job of pharmacy tech so very satisfying at the end of the day.

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