Prescriptions on a fixed benefit plan work differently from a copay plan, and once you see the mechanism it is refreshingly transparent. There is no formulary tier to decode and no prior authorisation to lose an afternoon to. The plan tells you what it pays, up front, and it pays it.

How it works, in three steps

  • The pharmacy prices the drug. That is the starting number.
  • The network reprices it. Your plan gives you access to a nationwide PPO network, which negotiates lower rates before the plan pays anything.
  • The plan pays its scheduled amount. A set figure for a generic, a larger set figure for a brand name.

On the plan level we most often recommend in North Carolina, that is $20 toward every generic fill and $60 toward every brand-name fill. Those are the carrier's published figures for that plan and state; amounts differ by plan level, so ask for the schedule on the one you are actually being offered.

For most people's medication list, this simply covers it

Here is the part that gets lost in the online debate about these plans. The medications most households take every day — blood pressure, cholesterol, thyroid, metformin — are generics that commonly run a few dollars a fill at a national pharmacy. A $20 benefit against a $10 prescription does not leave you short. It covers the fill outright.

That is the ordinary case, and it is the case nobody writes about. The plan quietly handles it every month.

The allowance goes up after your first year

A genuinely good feature that is easy to miss. The plans we place increase several benefits once you have held the plan through your first full calendar year, and prescriptions are one of them. On that level, the number of fills the plan pays for rises from 12 in year one to 17 in year two. On the top plan level it goes from 20 to 25.

So the plan you buy is not the plan you keep — it improves by staying put. Worth knowing before you shop it again in eleven months. The counting itself is worth understanding properly, and we have set it out in what a fills-per-year limit means if you take several medications.

What sits behind the benefit

Two things come with every plan we place in this category and both are useful on the prescription side:

  • Unlimited $0 virtual visits through a national telehealth service. A doctor can diagnose and prescribe by phone or video, 24/7, at no additional cost — which is often the fastest route to a prescription in the first place. This is a telehealth service, not insurance, and visits with psychiatrists, psychologists and dermatologists carry additional fees.
  • A prescription discount card, included with the plan, which the carrier reports can save 30–80% on prescription drugs against a pharmacy's usual and customary price. It is a discount programme rather than insurance, and it is available to the general public — so treat it as a useful tool rather than a benefit the policy owes you. We explain the difference in prescription discount cards are not insurance.

Ask the pharmacy before you assume

A habit worth forming. Pharmacies do not all charge the same for the same drug, and the difference on a common generic can be several times over between a supermarket counter and a hospital outpatient pharmacy a mile away.

Before you fill something new, ask what the cash price is and what the price is with the discount card that came with your plan. Then compare both against what the schedule pays. It takes one phone call and it occasionally saves a fill that would otherwise have been spent for no benefit at all.

The honest exception: high-cost brand names

If you take a specialty or brand-name medication that runs several hundred dollars a month, a $60 benefit toward it is not going to close that gap, and we will say so on the first call rather than the third. That is not a defect in the plan — it is what a fixed benefit is — but it is the one situation where the arithmetic decides the answer for you.

When that comes up, we work the problem rather than push the product. Sometimes there is a therapeutic alternative worth raising with the prescriber. Sometimes a manufacturer assistance programme applies. Sometimes the right answer is a comprehensive plan where the drug can sit on a formulary tier, and we are licensed to sell you that instead. The broader version of that judgement is in who should not buy limited medical.

Bring your list and we will price it

This is a ten-minute exercise and it removes all the guesswork. Write down every medication you take and what the pharmacy charges today. Then take three figures from the plan's schedule:

  • What it pays per generic fill
  • What it pays per brand-name fill
  • How many fills per year it covers, in year one and year two

Run your list against those three numbers and you will have a real monthly figure instead of an impression. In our experience most people are pleasantly surprised, and the ones who are not find out now rather than in March.

How The Jordan Insurance Agency helps

We are an independent agency in Charlotte, and our licensed agents have worked with North Carolina families since 2006. We do this arithmetic on the call with your actual medication list in front of us. That is the difference between reading a forum thread about fixed indemnity plans in general and getting an answer about your prescriptions on a specific plan in your state.

We also do not stop at the medical plan. Most of our clients carry an accident policy and a critical illness policy alongside it, because those are the events that produce the bills worth planning for — more on that in how a well-built fixed benefit plan is put together.

Do you mind if we take a look together?

Figures shown are the carrier's published amounts for one plan design available in North Carolina. There are several plan levels and the amounts differ between them, so we confirm the exact schedule for your plan and state before you apply. This product provides limited benefits. It is a supplement to health insurance and is not a substitute for the minimum essential coverage required by the Affordable Care Act.