Can You Use Secondary Insurance for Prescriptions?

Secondary health insurance is an additional policy that works with a primary plan to cover healthcare costs. It can cover expenses like copayments, coinsurance, and deductibles not fully paid by primary insurance. Secondary insurance can reduce out-of-pocket expenses for medical services, including prescriptions. Using secondary insurance for prescriptions is possible, but requires understanding how both plans interact.

Understanding Coordination of Benefits

Coordination of Benefits (COB) is the process used by insurance companies to determine how medical expenses are covered when an individual has more than one health insurance plan. This process clarifies which plan pays first, known as the primary payer, and which plan pays second, the secondary payer. COB rules prevent overpayment or duplicate payments, ensuring that the combined benefits do not exceed the total cost of the medical service.

When an individual has multiple insurance plans, the primary plan is responsible for processing the claim first and paying its share. After the primary plan has paid, the secondary plan then reviews the remaining balance and pays according to its own coverage limits and rules. For instance, if a medical bill is $250 and the primary plan covers $200, the secondary plan would then consider the remaining $50. You may still be responsible for deductibles, copayments, and coinsurance, even with two plans.

Several common rules determine which plan is primary and which is secondary. If you are covered by your own employer-sponsored plan and also as a dependent on a spouse’s plan, your employer’s plan is typically primary. For dependent children covered by both parents’ plans, the “birthday rule” often applies: the plan of the parent whose birthday falls earlier in the calendar year (month and day) is primary, regardless of the year of birth. If both parents share the same birthday, the plan that has provided coverage for the longer period usually becomes primary.

If an individual has continuation coverage, such as through the Consolidated Omnibus Budget Reconciliation Act (COBRA), and also has another plan, the plan covering them as an employee or member is generally primary, and COBRA coverage is secondary. COBRA allows individuals to continue their employer group health plan coverage for a limited time after certain qualifying events, such as job termination or reduction in hours. Medicare eligibility can also impact COB rules, with specific guidelines determining whether Medicare or another plan pays first, often depending on the size of the employer.

Preparing to Use Secondary Insurance for Prescriptions

Before using secondary insurance at a pharmacy, gather information and understand both your primary and secondary plans. You will need both insurance cards, along with policy and group numbers. Having these details readily available streamlines the process at the pharmacy counter.

Understand each plan’s coverage details. This includes reviewing its formulary, a list of prescription drugs covered fully or partially. Formularies are often organized into tiers, with lower tiers typically including generic drugs with smaller patient cost-sharing. Higher tiers cover brand-name or specialty drugs with higher out-of-pocket costs. Checking formularies for your medications ensures they are covered by at least one plan.

Understand each plan’s financial responsibilities. Familiarize yourself with the deductibles, copayments, and coinsurance requirements for both primary and secondary insurance. A deductible is the amount you pay out-of-pocket before insurance pays for covered services. A copayment is a fixed amount paid for a service, like a prescription, at the time of service. Coinsurance is a percentage of the cost you pay after your deductible is met.

Confirm which plan is primary and which is secondary for your situation. This is based on Coordination of Benefits rules. While general rules exist, individual circumstances like multiple employer plans or dependent coverage can influence this order. Knowing this helps ensure claims are processed correctly and minimizes potential delays or unexpected costs.

Applying Secondary Coverage at the Pharmacy

When filling a prescription with both primary and secondary insurance, specific steps ensure proper claim submission. Inform the pharmacist you have two health insurance plans. It helps to state which plan you believe is primary and secondary, based on your research.

Present both your primary and secondary insurance cards to the pharmacy staff. These cards contain the necessary policy and group numbers that the pharmacy needs to submit claims. The pharmacist will typically enter the information for your primary insurance first into their system.

The pharmacy’s system will then process the prescription claim through your primary insurer. Once the primary plan has adjudicated the claim and paid its portion, the system will automatically, or with the pharmacist’s manual input, process the remaining balance through your secondary insurance. This sequential processing ensures that the benefits are coordinated correctly, with the secondary plan considering what the primary plan has already covered.

After both plans have processed the claim, the pharmacy system will calculate your final out-of-pocket cost. This remaining amount typically reflects any deductibles, copayments, or coinsurance that were not covered by either plan, or a significantly reduced amount compared to using only one plan. In some cases, the secondary coverage might reduce your copayment to zero, depending on the specific terms of your plans. If the pharmacy encounters any issues during this process, they can often contact a pharmacy help desk for assistance, using a phone number usually found on the back of your prescription card.