Navigating the System

Empower yourself as a patient, and learn how to get the most out of your benefits. Each plan is different, so this section of our guide will help you understand what it is that you should look for when you receive your insurance information.  This section will help you navigate the health care system when you need care.

Topic Area: Prescription drugs

What will my prescription cost?

How much you will pay depends on where you fill your prescription, what “tier” your plan puts that drug in, and how your plan works.

Which pharmacy you use makes a difference

Learn where you can fill your prescription and where you’ll get the best deal:

  • Most plans require you to use in-network pharmacies. Other plans allow you to use out-of-network pharmacies, but you’ll likely pay more.
  • Some plans require you to use mail-order for medications you take regularly. Others don’t require mail order, but you can save a lot by using it. Learn more
  • If your medication is very expensive or requires special handling, you may be required to use your plan’s specialty pharmacy.

Your cost will depend on which “tier” your prescription is in

Most health plans have a list of drugs that they cover called the formulary, which is different from plan to plan. Learn more.

Each time you fill a prescription, you will pay some, or all of the cost. You will either pay a benefit copay or a cost sharing based on a percentage (called coinsurance) of the total. In some insurance products, you may also have a deductible that applies to prescription medications.  Under most plans, your cost share depends on which “tier” they put your drug in and the contract between your insurance company and the pharmacy. Your plan may have 2, 3, maybe even 6 different tiers.

Generic  $

Brand-name  $$$

Specialty  $$$$

Preferred generic  $

Preferred brand-name  $$$

Preferred specialty  $$$$

Non-preferred generic  $$

Non-preferred brand-name  $$$$

Non-preferred specialty  $$$$$


New Hampshire law requires that commercially insured patients receive the full benefit of going to an in network pharmacy.  The law requires that a patient pay no more than the lowest of the following:  the copay amount, the drug charge (retail or sticker price), or the negotiated payment amount in the contract between the health insurer and the pharmacy.  For example: 

  • $25 copay
  • $20 drug charge
  • $10 negotiated contract amount  

The patient would pay $10 in this example.  If you feel you may have overpaid, contact your insurance company or the NH Insurance Department

Learn how your plan works

  • The type of health plan you have makes a difference. Even if a medication is covered by your plan, you may have to pay the full cost until you meet your annual deductible. Learn more about how prescription drugs are covered under different types of plans. If you’re on Medicare, your prescription drug coverage is very different depending on whether or not you have supplemental insurance. Learn more
  • Your plan may require you to try a cheaper option first. Many times there are several treatment options for a health concern. Your doctor may prescribe the latest brand-name drug. But, your plan may say you need to try the generic option first. Then, only if it turns out that less expensive option doesn’t work for you for some reason will they cover the brand-name version. This is sometimes called step therapy.  However, New Hampshire law prohibits requiring a patient to fail on the same medication on more than one occasion.
  • In general, plans don’t cover experimental treatments or items such as herbal remedies or vitamins (except prenatal vitamins often are covered), so it’s important to check the list of exclusions in your Summary of Benefits and Coverage Document as well.
  • Some prescriptions may be available at no cost to you. Some plans provide prescriptions for certain chronic conditions for free. Currently, most plans cover contraceptives at 100%.
  • Over-the-counter medications may be covered, if your doctor prescribes them. The Affordable Care Act requires some over the counter drugs to be covered at $0 cost share, such as aspirin, for prevention. Some insurance companies require you to get a prescription for coverage. Check to know your coverage.
  • Call your plan to verify coverage if you’re not sure. Don’t be surprised by unexpected costs.
  • Additional information:  the New Hampshire legislature has adopted a number of patient protection initiatives related to accessing prescription drugs by commercially insured patients.   


Was this answer helpful?