Consumers: Are You Getting the Most Out of Your Rx
Drug Benefit?
Tips to Help Choose and Understand Prescription Drug
Benefits for Open Enrollment
WASHINGTON, DC (November 9, 2004) — What:
When choosing a health plan, most consumers check the cost and also
make sure their personal doctor is in the new plan’s network,
but they may overlook equally important concerns, especially whether
the prescription medicines they are taking are affordable and accessible,
according to the National Consumers League and the National Pharmaceutical
Council.
New tips are available to help consumers choose the prescription
drug coverage that’s right for them and to understand how
the coverage works. At www.yourpharmacybenefit.org,
consumers can learn what questions to ask when choosing a prescription
drug benefit, become familiar with commonly used terms, and ultimately
make the choices that are best for them.
Why: Prescription drug benefits are not all the
same and understanding and choosing new plans can be confusing.
With “open enrollment” season here, consumers are working
to familiarize themselves with new health plan benefits. Learning
how drug coverage works will help consumers choose the best plan
for them and their families and ensure they get the medicines their
doctor prescribes with little hassle.
The tips for consumers will arm them with the questions they need
to ask. (These tips are included at the end of this advisory.)
Tips for Choosing Your Prescription Drug Coverage
When choosing a health plan, it is as important to make sure the
medicines you take regularly are covered as it is to know that your
doctor is in the network. Most health plans cover prescription medicines,
but the rules may be different than those for other medical services.
In addition, pharmacy benefits may not be administered by the same
company as the physician and hospital benefits, but rather by a
separate company, called a pharmaceutical benefits manager or “PBM.”
Before you decide on a health plan, get the facts you need about
the benefit:
- Find out if the health plan or PBM has a limited list
of drugs it will cover. This is known as a formulary.
If someone in your family takes medications for a chronic illness,
like high blood pressure, asthma, or diabetes, be sure those medicines
are on the formulary before you select that plan. If they aren’t,
you will most likely be expected to switch to different medications
or pay for them without insurance, unless you win overage on
appeal.
- Find out how to file an appeal if the medicine you
need is not covered by your insurance. If the medicine
you need is not on the formulary, you usually can file an appeal
with the health plan to request them to cover it anyway. You will
not be notified of your right to appeal when you are denied coverage,
so it is important to find how to file an appeal on your own.
Your doctor will need to provide the information to explain why
you need that specific medicine.
- Find out how much you have to pay when you fill a prescription.
Most plans require you to pay a co-payment for each prescription.
Many lans have three or even four levels, or tiers, of co-payments
that apply to different medicines. Find out what co-payment level
applies to the medications you are taking. If it is more than
you can afford, you may want to ask your doctor if there are other
medicines on a lower tier that would be appropriate for you.
- Find out if the health plan has to pre-approve certain
drugs before you can fill the prescription. Many plans
require your doctor to have “prior authorization”
for some medicines before it will pay for them. That means your
physician or pharmacist must call for permission to prescribe
these medications. Some plans also require you to try a essexpensive
medicine before it will pay for the one your doctor might otherwise
recommend. Check with your doctor to see if the less expensive
medicine is right for you. If you need a certain medication for
a valid medical reason, you can often get it covered by filing
an appeal. If you can’t wait for the appeal process to finish,
you may need to pay for the medicine yourself and then file an
appeal to be reimbursed by the plan.
- Find out if the health plan offers a mail order option.
Some plans offer a mail order service for medicines and offer
incentives like lower co-payments to encourage you to use it.
Other plans have mandatory mail der services and require you
to order your long-term medications through the mail. The plan
will not pay for them if you try to obtain them at a local pharmacy.
More information on making informed decisions about your prescription
drug coverage is available at www.yourpharmacybenefit.org.
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Please direct all media inquiries to Pat Adams, phone
(703) 620-6390.
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