Does CHIP cover prescription drugs?
Are medications covered under CHIP, and do I need to pay for my child’s prescriptions?
Yes, prescription medications are covered under the Children’s Health Insurance Program (CHIP) in Utah. CHIP ensures that children have access to the medications they need to manage both acute and chronic health conditions. While most medications are covered, families may need to pay small copayments based on their household income. Here's what you need to know about prescription drug coverage under CHIP.
1. Prescription Drug Coverage Under CHIP
CHIP in Utah provides comprehensive coverage for a wide range of prescription medications, including:
Generic medications: CHIP covers the cost of most generic drugs, which are often preferred because they are effective and cost less.
Brand-name medications: If a generic version is not available or medically appropriate, CHIP also covers brand-name drugs.
Specialty medications: For children with specific conditions (such as asthma, diabetes, or rare diseases), CHIP covers specialty medications needed for treatment.
A. Medications for Chronic Conditions
CHIP covers medications required to manage chronic conditions such as:
Asthma inhalers.
Insulin and other medications for diabetes.
Antibiotics and antivirals.
Mental health medications, such as antidepressants or ADHD medications.
B. Over-the-Counter Medications
Certain over-the-counter (OTC) medications may also be covered if prescribed by a doctor. Examples include:
Pain relievers such as acetaminophen or ibuprofen.
Antihistamines for allergies.
Vitamins or supplements, if medically necessary.
2. Do I Need to Pay for My Child’s Prescriptions?
While CHIP provides coverage for most medications, you may be required to pay small copayments for your child’s prescriptions. The amount you pay depends on your household income.
A. Typical Copayments for Prescriptions
Generic drugs: Copayments for generic medications are usually around $5 or less.
Brand-name drugs: Copays for brand-name medications are generally higher, typically ranging from $10 to $15.
Specialty drugs: Copays for specialty medications may be higher, but CHIP ensures that these costs remain affordable for families.
B. Out-of-Pocket Maximum
CHIP sets an out-of-pocket maximum for all healthcare services, including prescriptions. This means that once your family reaches the out-of-pocket maximum for the year, you will not have to pay any more copays for prescriptions or other medical services for the remainder of the year.
3. How to Access Prescription Drug Benefits
To access prescription drug coverage under CHIP:
Present your CHIP benefits card: When filling a prescription at a pharmacy, present your child’s CHIP benefits card to confirm coverage.
Use an in-network pharmacy: Be sure to use a pharmacy that accepts CHIP to avoid additional out-of-pocket costs. Most major pharmacies and local drugstores accept CHIP.
4. What to Do If a Medication Is Not Covered
If a prescribed medication is not covered by CHIP, you have options:
Ask your doctor for alternatives: Your healthcare provider may be able to prescribe a generic or alternative medication that is covered.
Request prior authorization: For some medications, your doctor may need to submit a prior authorization request to CHIP to demonstrate the medical necessity of the medication. If approved, the medication will be covered.
Appeal the decision: If a medication is denied, you can appeal the decision and provide additional documentation from your doctor to support the need for the medication.
Key Takeaways:
CHIP in Utah covers most prescription medications, including generic, brand-name, and specialty drugs.
Families may need to pay small copayments for prescriptions, but CHIP sets an out-of-pocket maximum to limit annual expenses.
Over-the-counter medications may also be covered if prescribed by a doctor.
For help understanding your child’s prescription drug coverage under CHIP or finding an in-network pharmacy, schedule an appointment with a Tsunami Advisor here: Schedule an Appointment.
