Some medications are intended for use by members who are over or under a certain age. If a member doesn’t meet this age requirement, the doctor prescribing the medication must send documentation to the pharmacy.

A limit on the benefits your insurance company will pay each year. These limits are sometimes placed on particular services such as prescriptions or hospitalizations. Annual limits may be placed on the dollar amount of covered services or on the number of visits that will be covered for a particular service. After an annual limit is reached, you must pay all associated health care costs for the rest of the year.

The type of coverage offered for certain health care items or services covered by your health insurance plan. Covered benefits and excluded services are defined in your health insurance plan’s coverage documents. In Medicaid or Children’s Health Insurance Program (CHIP), covered benefits and excluded services are defined in state program rules.

A brand-name drug is one that is developed and patented by a specific company.

A generic drug is a prescription drug that is chemically equivalent to a brand-name drug and has the same dosage form, safety, strength, route of administration, quality, performance characteristics and intended use as a brand-name drug.

Generic drugs usually cost less than brand-name drugs. The Food and Drug Administration (FDA) rates approved generic drugs to be chemically equivalent and as safe and effective as brand-name drugs.

A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered by your insurance plan.

An out-of-pocket cost you may be required to pay that is likely a percentage of the cost for services after you pay any deductibles. For example, if your health insurance plan’s coinsurance rate was 20 percent and you’ve already met your deductible, the amount you have to pay for a $100 doctor office visit is $20. Your health insurance plan pays the rest of the cost – $80.

An amount you may be required to pay for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or prescription medication. A co-payment, often called a “co-pay,” is usually a set amount rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription medication no matter what the total cost is. Co-pays typically vary depending on your health insurance plan.

Co-pay assistance programs, sometimes called “patient assistance programs,” are often funded by pharmaceutical companies, patient groups and medical foundations. These programs provide financial assistance to patients who need help paying for health care treatment and qualify for the programs’ medical and financial requirements. Patients can apply directly for these programs, or physicians, social workers or pharmacists may apply on a patient’s behalf.

Co-pay vouchers for prescribed medications, sometimes called “coupons,” are provided by some pharmaceutical companies and are often distributed by a physician or pharmacist to help you pay for your prescription medications. Alternatively, some may be found online. A voucher may eliminate your co-pay altogether or reduce it to a specific price. Government-funded insurance programs like Medicare Part D and Medicaid prohibit the use of vouchers. However, you can use these vouchers if you’re in the Medicare Part D “donut hole.”

Community Pharmacy can accept some co-pay vouchers depending on the fine print. We do not accept GoodRX, as they do not reimburse us for the amount the patient saves.

An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit or prescription drug. Cost-sharing can include co-payments, co-insurance and deductibles. If you are a Medicaid or Children’s Health Insurance Program (CHIP) beneficiary, your premiums are also considered cost sharing.

If you are enrolled in Medicare Part D prescription drug coverage, a coverage gap is the period of time in which you are responsible for paying a higher portion of the cost for your prescription drugs until you spend enough to qualify for catastrophic coverage. The coverage gap, also called the “donut hole,” starts when you and your plan have paid a set dollar amount for prescription drugs during that year. (See Donut Hole)

The amount you must pay for health care services or prescription medications each year before your insurance begins to pay. For example, if your deductible is $1000, your insurance will not pay anything until you have incurred $1000 out-of-pocket for covered health care services or prescription medications. The deductible may not apply to all services.

Requesting your health care provider note “dispense as written,” “medically necessary” or “do not substitute” on your prescription or e-prescription ensures your pharmacist will check with you and your health care provider before any substitutions or changes to your prescription occur. It is also necessary to dispense some name brand medications when going through your insurance.

If you are enrolled in Medicare Part D prescription drug coverage, the donut hole is the period of time in which you are responsible for paying a higher portion of the cost for your prescription drugs until you spend enough to qualify for catastrophic coverage. The donut hole, also called the “coverage gap,” starts when you and your plan have paid a set dollar amount for prescription drugs during that year. (See Coverage Gap)

Sometimes your insurance may reject a medication due to its interaction with another medication you are on. We may have to reach out to your provider or get consent from you to fill medications with a drug-drug interaction.

If you are a Medicare beneficiary, your health care provider may request an exception when the drug he or she prescribes is medically necessary for you but is not included on your formulary or is included on a tier that requires you to pay a greater out-of-pocket cost. A “formulary exception” is a drug plan’s decision to cover a drug that is not on its drug list or to waive a coverage rule. A “tiering exception” is a drug plan’s decision to charge a lower amount for a drug that is on its non-preferred drug tier. You must request an exception, and your health care provider must send a supporting statement explaining the medical reason for the exception.

A list of prescription drugs covered by your prescription drug insurance plan or another insurance plan offering prescription drug benefits. Also called a “drug list,” a formulary may include both generic drugs and brand-name drugs, as well as how much you would pay for each drug. If the insurance plan uses tiers, the formulary may list which drugs are in which tiers.

There are medications that a health insurance plan won't cover under any circumstance. Exclusions can include:

• Over-the-counter medications.

• Experimental, investigational or unproven therapies.

• Medications used for cosmetic purposes.

Some prescription drugs are available through the mail. The drugs provided through mail order are usually drugs taken on a regular basis for a chronic or long-term medical condition.

Depending on your plan type, mail-order benefits may vary but are usually quicker and much less expensive.

While Community Pharmacy offers mail-order of prescriptions, we may not be considered a mail-order pharmacy by your insurance. Mail-order pharmacies typically do not have in-person locations and are contracted with certain insurances.

A state-administered health insurance program for low-income families and children, pregnant women, the elderly, people with disabilities and, in some states, other childless adults. The federal government provides a portion of the funding for Medicaid and sets guidelines for the program. States also have choices in how they design their program, so Medicaid varies state by state and may have a different name in your state.

If you are on Badgercare and your medication is not covered, you must get a prior authorization to have it covered, or a prior authorization rejection to pay out of pocket. You can request an expedited rejection from your provider if you know it will not be covered by Badgercare.

An optional program for Medicare beneficiaries that provides prescription drug coverage. There are two ways to get Medicare prescription drug coverage: through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that includes drug coverage. These plans are offered by insurance companies and other private companies approved by Medicare.

The federal health insurance program for people ages 65 or older, certain younger people with disabilities and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

Expenses related to health services or prescription drugs that you must pay on your own above and beyond your monthly health insurance premium. Depending on your health plan, out-of-pocket costs may include an annual deductible, co-insurance and co-payments.

The most you have to pay during a policy period (usually a year) before your health insurance plan begins to pay 100 percent of your health care claims. This limit never includes your monthly premiums or health services/items your health insurance plan doesn’t cover. Some health insurance plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit. In Medicaid and the Children’s Health Insurance Program (CHIP), the limit includes premiums.

A pharmacy that’s part of the your insurance’s network where you can receive covered medications, usually at a lower cost.

A third-party company that handles the drug insurance benefit program for employers and public and private insurance companies. Pharmacy benefits managers, abbreviated PBMs, often process and pay for drug claims, develop and maintain formularies, work with pharmacies and negotiate discounts and rebates with pharmaceutical manufacturers.

One of the biggest PBMs is CVS/Caremark, which often funnels patients to CVS by offering them lower copays at their pharmacies. They also oftentimes reimburse independent pharmacies less than the cost of the medications, leading them to send patients elsewhere.

Approval from your health insurer that a health care service, product or prescription drug is medically necessary and will be covered by your health insurance. Your health insurance plan may require prior authorization for certain services before you receive them, except in an emergency.

If you are on Badgercare and your medication is not covered, you must get a prior authorization to have it covered, or a prior authorization rejection to pay out of pocket. You can request an expedited rejection from your provider if you know it will not be covered by Badgercare.

A person or organization that is licensed to provide health care services. Doctors, physician assistants, nurse practitioners, registered nurses and pharmacists are examples of health care providers.

Health insurance plans set limits on the amount of a medication they’ll cover over a certain period of time. These limits are set for safety and quality reasons. Both formulary and non-formulary drugs may have quantity limits.

Specialty drugs are prescription drugs that treat complex conditions and require special handling and administration. This type of drug is usually very expensive, requires prior authorization and may have to be ordered through a specialty pharmacy.

Besides handling specialty drugs, specialty pharmacies coordinate patient care and disease management for chronic and complex conditions.

A practice used by public and private health insurers, pharmacy benefits managers (PBMs) and companies that process and pay for prescriptions that divides medicines into three or more tiers, typically: generic, branded and preferred. Each tier is assigned a different co-payment. Many insurance plans have now added a specialty tier, which is a fourth category of medicines that requires you to pay co-insurance, or a percentage of the drug price.

A coverage rule used by some health and prescription drug insurance plans that requires you to try one or more similar, lower cost drugs to treat your condition before the plan will pay for the prescribed drug.

Therapeutic substitution means the drug originally prescribed to you has been switched by a pharmacist to another drug that is a different chemical compound. This is different than generic substitution, where a branded drug prescribed to you is switched to its generic equivalent, meaning one approved by the United States Food and Drug Administration (FDA) as a chemical equivalent with the same dosage strength.