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Medications are usually one of the biggest expenses in healthcare. Having medical insurance in place helps to reduce financial strain and cut out-of-pocket expenditures for households. It is therefore essential that you understand how your insurance works, particularly when it comes to prescription medications.

Unfortunately, many patients do not take the time to understand the basics of their health insurance plan and how it works. Most insurance plans cover prescription medicines, but the specifics vary. Before filling a prescription, check if the medicine is covered under your plan to avoid unexpected costs at the pharmacy counter.

Understanding your health insurance plan

  • Premium: A fixed amount of money you pay each month or annually to have a plan. Think of it as a membership fee.
  • Deductible: The amount of money you pay for covered medical expenses before the insurance plan takes effect
  • Co-pay: A fixed amount of money you pay for a covered service after you have met your deductible.
  • Annual limit: The maximum amount the insurer will pay in a year.
  • Formulary: An official list of medicines that the insurer will pay for. They are often classified into tiers, and the copays will vary depending on the tier of drugs. Tier 1 drugs are low-cost generics, tier 2 drugs are the preferred brand-name drugs, and tier 3 are non-preferred brands.
  • Exclusions: Medications that the insurer does not cover. In Kenya, this varies from plan to plan. For instance, certain insurance providers do not cover vitamins and supplements, cosmetic treatments, weight loss treatments, baby formulas, and treatments for certain conditions, such as infertility
  • Preauthorization: Some insurance plans require that justification and approval is provided before they pay for certain treatments, such as high-cost specialized drugs or certain exclusions that are part of treatment

What you need to check before filling your prescription:

Always check:

  • The list of covered medicines (formulary) and exclusions.
  • Whether coverage applies to specific brands, generic brands, or both.
  • If there are limits to the cost per refill.
  • How many months’ supply can you get at once without preauthorization.
  • If your preferred facilities are on the panel of accredited facilities.
  • If the prescription and diagnosis require preauthorization before the insurer pays for the drugs
  • What documentation is required: In most cases, you need to have a valid prescription and a claim form with all the necessary information filled in. Some insurers require medical reports for some specialized and imported drugs. Others may ask for laboratory test results before they pay for certain treatments, for instance, vitamin and mineral deficiencies.

When in doubt, always consult your pharmacist or your insurer.

The connection between your plan and your prescription

Most plans in Kenya have a “formulary” of medications that they cover and those that they do not. Having a health insurance plan in place does not mean that your prescription is automatically covered. Coverage can vary depending on the insurance provider and the type of plan (private or employer-based).

Even with coverage, patients may face out-of-pocket costs for non-listed or imported drugs or limited access to newer specialized drugs. Sometimes, medicine stockouts at approved facilities may force patients to purchase medications elsewhere.

Most insurance plans cover:

  • Essential medicines in the national formulary.
  • Chronic disease medications, eg, Diabetes, hypertension, asthma.
  • Emergency treatments and hospital-covered drugs.

How to save money on your prescription

  1. Ask for generics: You can ask your doctor to prescribe a generic brand instead of a brand-name medication. Generics are just as effective as branded drugs. This will save you a significant amount of money. Discuss this with your doctor and pharmacist, as certain conditions require brand consistency, eg, thyroid disorders and epilepsy.
  2. Check different pharmacies and compare prices. The cost of medicines varies from one pharmacy to the other.
  3. Explore patient assistance programs. For some conditions, pharmaceutical companies often provide low-cost medicines to certain patients who qualify.
  4. Know your formulary by asking your provider for a list of covered medicines and exclusions.
  5. Use discount programs at pharmacies.
  6. Keep receipts: Some plans reimburse after the purchase.
  7. Review your plan annually to ensure it still covers your needs, since benefits can change.
  8. Use accredited facilities since coverage may be denied at some facilities.
  9. Appeal if denied coverage: If you are denied coverage for a necessary medication, your doctor can help you appeal by justifying the treatment.

Final dose of clarity

Do not wait until you are sick to find out if you are covered or not. Always read your policy documents and speak to your insurer about your prescription needs. Communication with your healthcare providers can help you lower costs. Talk to your doctor and pharmacist about your insurance plan and financial concerns. They can recommend less expensive alternatives, offer drug samples, or even refer you to facilities and programs that can help save costs.

Do you have questions about your medication coverage? Share them in the comments.

Disclaimer: Health information shared here is for education only. Please speak to your doctor or pharmacist before making decisions about your health or medications.

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