Knowing the Rules: Consumers Must Understand Health
Plan Rules to Ensure Uninterrupted Access to Needed Medications
Advice to Help Consumers Get What They
Need from their Prescription Drug Benefit
WASHINGTON, D.C. (February 2, 2006) – The new plan year often brings a change
to health insurance plans and the rules that go along with them.
For consumers becoming familiar with new plans and seniors starting
to use their Medicare prescription drug benefit, this may mean trouble
when filling prescriptions for the first time.
But even those who are continuing on with the same plan as last
year may experience some of the same frustrations. Rules can vary
from health insurance plan to health insurance plan and even from
one pharmacy visit to the next because plans are allowed to make
changes throughout the year. And consumers may not be aware of issues
that may impact copayments and lists of preferred medicines, thus
causing problems when trying to fill a prescription.
In an effort to help consumers to become educated and prepared,
eleven groups representing consumers, pharmacy, physicians, patients
and pharmaceutical companies have teamed up to provide free tips
and resources to help consumers understand how prescription drug
benefits work and find out what to do if coverage for their medicine
is denied. The program offers guidance for navigating drug coverage,
tips for troubleshooting problems, and a sample appeal letter and
a glossary of important terms, available at www.YourPharmacyBenefit.org.
"Pharmacists can be a patient's greatest ally in navigating
new drug coverage programs," said Mary Ann Wagner, the senior
vice-president for pharmacy, policy and regulatory affairs at the
National Association of Chain Drug Stores. "They are highly
trained and thoroughly familiar with patients and their medicines.
The resources offered by www.YourPharmacyBenefit.org
are more valuable tools for helping patients make sure their healthcare
needs are met."
The program offers several tips to help consumers who encounter
problems filling a prescription, including situations where:
- The information your pharmacy has about your plan doesn’t
match what is on your pharmacy benefit ID card.
- It’s too early to refill the prescription.
- A particular medication may react badly with another medication
you’re on or with another medical condition you have.
- The medicine your doctor prescribed requires your plan’s
prior approval.
- The medication is not covered by your health plan, or is not
on the “formulary,” the list of medicines covered
by the plan.
The Web resource explains all of these situations and provides
tips on how to resolve these problems. It also provides other important
information including how to understand “insurance-speak,”
and who to contact when questions arise. It also explains to consumers
how to file an appeal if the plan refuses to cover a medicine the
patient needs.
"Consumers will find this site helpful in giving them information
about how prescription drug coverage works so they can ensure their
medicines are accessible and affordable,” said Gary A. Puckrein,
PhD, Executive Director, National Minority Health Month Foundation.
“Nobody wants to be surprised by having to pay out of pocket
for a prescription they thought their insurance would cover."
For more information and for a list of current partners, please
see www.YourPharmacyBenefit.org.
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Please direct all media inquiries to Pat Adams, phone (703) 620-6390.
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