The standard package covers most medicines prescribed by your generalpractitioner or consultant. In some cases you may have to pay part of the costyourself. Or your insurer may only provide full cover for the cheapest versionof a drug. The cost of medicines that are covered by your insurance policy isfirst deducted from your excess.
Cover for registered drugs
Health insurers only provide cover for registered drugsthat are included in the Medicines Reimbursem*nt System.
Cover for non-registered drugs
Health insurers normally do not provide cover for medicines that are notregistered, except in the following exceptional circ*mstances:
- the non-registered drug is a last resort, as no further treatment optionsare available for your condition in the Netherlands;
- you have a very rare disease that affects no more than 1 in 150,000 peoplein the Netherlands;
- no equivalent medicine is registered for treating your condition.
Cover for branded drugs
Most health insurers only provide cover for the cheapest version of amedicine. It contains the same active ingredient or is essentially the same asthe branded drug. Your insurer may agree to reimburse the more expensivemedicine if your doctor has prescribed it for a medical reason. For instance,you may be allergic to certain ingredients in the cheaper drug. In that case,the doctor must write ‘medically necessary’ on the prescription.
Finding information about cover for medication
You can find information about cover for medication onMedicijnkosten.nl (in Dutch). Thiswebsite tells you:
- whether the medicine is covered by the standard health insurance package;
- what part of the cost will be deducted from your excess;
- whether you have to pay part of the cost;
- if a cheaper alternative is available for which your insurer provides fullcover.
Co-payment for medicines
There are various reasons why your insurer may require you to pay part of thecost for a drug. Medicines are grouped into categories. Drugs in the samecategory are essentially equivalent, but their prices may differ. The standardpackage sets a maximum price for every category of drug. If you buy a medicinethat costs more than the maximum price, you will have to pay the difference. Youcan take out additional insurance to cover these costs.
Co-payment for Concerta and Strattera
The drugs Concerta and Strattera are frequently used to treat ADHD. Aco-payment is required for these drugs. This is because they fall under the samecategory as methylphenidate (Ritalin), which is cheaper. There are no majordifferences between Concerta, Strattera and Ritalin, so full cover is onlyprovided for Ritalin, since it is the cheaper drug.
FAQs
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.
How do I tell if my insurance covers a medication? ›
Call your insurer directly to find out what is covered. Have your plan information available. The number is available on your insurance card the insurer's website, or the detailed plan description in your Marketplace account. Review any coverage materials that your plan mailed to you.
What is a list of drugs approved by an insurance company called? ›
Health plans usually have a list of drugs they have already approved for coverage. This list is called a formulary. Health plans often place drugs into different drug tiers on the formulary.
Why are some medications not covered by insurance? ›
In some cases, certain medications may be excluded from coverage due to their potential misuse or abuse. Formularies often don't cover brand-name or expensive drugs when generic or less expensive medications are available. Each plan's formulary is different, so it's important to check with your insurance provider.
How to get Ozempic covered by insurance? ›
How to get Ozempic covered by insurance
- Review your health insurance plan. Reach out to your insurance provider to get a better understanding of what's covered by your plan. ...
- Get a prescription. ...
- Obtain prior authorization, if needed. ...
- Request an appeal, if necessary.
Generic metformin is covered by most Medicare and insurance plans, but some pharmacy coupons or cash prices may be lower.
What is a list of drugs covered by an insurance plan and typically includes generic and brand name forms of a drug? ›
To do that, you'll want to know how to access your plan's Prescription Drug List (PDL), sometimes called a formulary. The PDL is a list of the most commonly prescribed medications. It includes both brand-name and generic prescription medications approved by the U.S. Food and Drug Administration (FDA).
What drugs will Medicare pay for? ›
All Part D plans must include at least two drugs from most categories and must cover all drugs available in the following categories:
- HIV/AIDS treatments.
- Antidepressants.
- Antipsychotic medications.
- Anticonvulsive treatments for seizure disorders.
- Immunosuppressant drugs.
- Anticancer drugs (unless covered by Part B)
What is the Cigna Healthcare Comprehensive Drug List? A drug list is a list of covered drugs selected by Cigna Healthcare in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program.
Why is my insurance rejecting my prescription? ›
The most common type of medication-related insurance rejection providers face is a prior authorization (PA). Insurance companies (payers) use PAs to increase prescribing of medications on their preferred formulary. “Refill too soon” and out-of-network rejections are also common.
Predictability. GoodRx's prices “fluctuate frequently — daily, weekly or monthly” the company's website says. So it might be hard to predict what you'll pay and where you'll have to go for your medications from month to month.
How do insurance companies decide which drugs to cover? ›
In practice, insurers use an internal committee or group, often called a pharmacy and therapeutics committee, to review formulary changes. According to the Insurance Department, these committees typically meet quarterly to review new drugs and, if the drugs are to be covered, determine the drugs' formulary tiers.
What is a medication list called? ›
A drug list, also called a formulary, is a list of prescription drugs covered by your health plan. Drug lists are usually divided into categories, or tiers.
What is a formulary or preferred drug list? ›
Simply put, a formulary is just another name for a drug list. A formulary is the list of generic and brand-name prescription drugs covered by a specific health insurance plan. Sometimes, health plan formularies are also referred to as preferred drug lists (PDLs).
What is a prescription drug plan has a list of drugs it covers called? ›
A plan's list of covered drugs is called a “formulary,” and each plan has its own formulary. Medicare drug coverage typically places drugs into different levels, called “tiers,” on their formularies.
What is a list of medications available for use within a healthcare system called? ›
In its simplest form, the formulary is a list of medications available for use at a hospital or health-system. This list includes the dosage forms, strengths and package sizes of each of the medications on it.
