Patient safety starts with you – National Consumers League

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Health care is not always as safe as we would like it to be. More than 10 years ago, the Institute of Medicine came out with a groundbreaking report that found that as many as 44,000 to 98,000 people die in American hospitals each year as a result of medical errors. What can consumers do to make sure they have a safe experience when they get health care?

Medical errors happen when what was planned as part of medical care does not work out, or when the wrong plan was used in the first place.) While there have been many efforts to improve safety over the last decade, progress is slow. Medical errors can happen anywhere you get your health services: in hospitals, clinics, a doctor’s office, nursing homes, pharmacies, and even in the patient’s home.

The best way you can help prevent errors is to be an active member of your health care team. That means taking part in decisions being made about your health care. Research shows that patients who are involved with their care tend to get better results. You can get better and safer care by asking questions about your diagnosis, treatment options, how you’re being cared for, and any medications prescribed for you.

Become an informed consumer.

Before seeking care, gather information about the illness or condition that affects you. Use reliable sources (like government Web sites such as the National Guideline Clearinghouse, Centers for Disease Control and the National Institutes of Health). Research options and possible treatment plans.

Choose a doctor, clinic, or hospital experienced in the type of care you require. For example, see the website developed by the Centers for Medicare and Medicaid Services, Hospital Compare, for information on comparing hospitals.

Keep track of your own medical history and your medications.

Write down your medical history, including medical conditions you have, illnesses, and hospitalizations. Keep track of all your medications (both prescription and over the counter) and dietary supplements (vitamins and herbs). This is called a personal medication record (PMR). There are several formats for keeping a PMR, and you should pick what works best for you.  Share all this when you visit the doctor, or go to the hospital or clinic.

Be a part of the team.

It’s your job to work with your doctor or other health care providers. Clear communication between patients and those that are taking care of them is critical to improving safety and reducing the risk of medical errors.

Make sure you share your health history and medication use with your team. The PMR is a good way of doing that.

Make sure you understand the care and treatment you are going to receive. Ask questions! The Ask Me Three program from the National Patient Safety Foundation encourages patients to ask their team these three important questions:

  1. What is my main problem?
  2. What do I need to do?
  3. Why is it important for me to do this?

Follow the treatment plan agreed upon by you and your doctor. Make sure you receive the instructions verbally AND they are written down for you.

Get a partner.

Involve a family member or friend in your care. Ask a family member or friend to be with you in the hospital or come along to appointments to speak up for you if you can’t. They can help you understand care instructions and be your advocate when it’s time to make decisions. It helps to have a second set of ears, especially if you are nervous or distracted about your condition.

More tips for: hospital stays

  • Don’t be afraid to remind doctors and nurses about washing their hands before working with you. You are part of the health care team and it is okay for you to remind them. Hand washing is one of the best ways to stop hospital infections, including the MRSA infection, which can be very serious.
  • If you are having surgery, make sure that you, your doctor and surgeon all agree and are clear on what exactly needs to be done. Some surgeons sign their initials directly on the site to be operated on before surgery.
  • If you have an intravenous catheter, to prevent infection tell you doctor or nurse if the bandage comes off or there is soreness around the catheter.
  • If you have a urinary catheter, make sure it is removed as soon as possible to prevent an infection. Ask your health care team every day if it can be removed.
  • Quit smoking. Patients who smoke get more infections.
  • When you are being discharged, ask your doctor to explain the plan to you, and write it down so that you understand what you need to do. Research shows that at discharge, doctors think their patients understand more than what they really do about what they should do when they are at home.

More tips for: medications

  • Make sure ALL your health care providers know ALL the medications, both prescription and OTC, as well as dietary supplements such as vitamins and herbs, that your are taking. Keep a Personal Medication Record (PMR), make sure it is up to date, and share it with your health care provider.
  • Tell your health care providers about any allergies and adverse reactions you have to medications.
  • When your health care provider write you a prescription, make sure you can read it and know what medicines you are being prescribed.
  • Ask about your medicines when you are prescribed them and when you receive them. Ask:
    • What is it for?
    • How long do I need to take it?
    • What side effects are likely, and what should I do if I have them?
    • Can I take it with other medicines and dietary supplements?
    • Is there any food or alcohol that I need to avoid while taking?
  • When you pick up your medicine at the pharmacy, ask if this is the medicine that was prescribed. Most medication errors involve the wrong drug or wrong dose.
  • If you have questions about the directions on the medicine label – ask!  Medicine labels can be hard to understand.  For example, does “three doses daily” mean take a dose every eight hours around the clock, or just during waking hours?

For more on this subject

National Patient Safety Foundation

Agency for Healthcare Research and Quality (AHRQ)

AHRQ’s Questions are the Answer

Fact sheets on Health Care Associated Infections (English, Spanish, and Large Print)

Health care reform: good for consumers and America – National Consumers League

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The lack of comprehensive health care coverage is America’s albatross – it makes our businesses less competitive and our workers less healthy. We need to put partisan concerns aside and work NOW to ensure that the system is reformed. The cost of doing nothing is unthinkable.

American families are paying about $15,000 a year for health care, twice as much as we did twenty years ago, and we pay $6,500 more for health care than any other industrialized country in the world. Yet despite these high costs we have poorer health outcomes.

We need to address why we are overpaying for care that is not making us healthier. Health reform, as proposed in several current bills in Congress, will move us towards greater accountability, efficiency, accessibility, transparency, and quality. It is essential that everyone have access to affordable health care or the system will remain broken.

For consumers, health reform will translate into choice – with a greater number of options available, including keeping and supplementing your own insurance, at more affordable and competitive prices. Reform will also make it easier to compare and understand the true costs and benefits of plans. As consumers and employees, we can make choices what will help push for health insurance and benefits that are competitive, innovative, and cost-contained.

With unemployment nearing 10 percent, many Americans have lost their employer-based coverage. Further, of the nearly 50 million uninsured, close to 80 percent are working Americans. It is imperative that we not leave our most vulnerable citizens out in the cold, which is why health reform will only be effective if everyone is covered.

Experts project that families will pay $10,000 more annually on medical costs by 2016 if we DON’T fix the system Health care coverage for all Americans is a moral imperative that must not be allowed to fall victim to partisan politics.

Dental care key to health reform – National Consumers League

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Providing preventative health care is one of the most important strategies for lowering our nation’s health costs. We hear a lot about the 46 million Americans without health insurance, but rarely do we hear that more than twice that lack dental insurance.

The case for dental coverage is the same as for health care. People without health care coverage often get sick with illnesses that could be treated at far less cost if caught early. When it comes to dental care, kids with minor tooth problems may end up with dental disease for the rest of their lives. This can hurt their ability to stay in school or get a job. Adults with missing teeth find it hard to get jobs as well.

But poor dental health can also kill you. The Washington Post ran a story about Deamonte Driver, a 12-year old who died of complications stemming from a toothache that could have been cured by an $80 tooth extraction. Deamonte’s family had lost its Medicaid coverage, and few dentists would even take Medicaid patients anyway. Bacteria from the tooth spread to Demonte’s brain, leading to hospitalization and two operations. The total cost of the hospital care was about $250,000, and the hospital was still unable to keep him alive.

The National Consumers League, with our long history of work on health care, has joined with several other groups including the American Dental Education Association, the Dental Health Foundation, and Oral Health America, in a campaign to underscore the importance of including dental care in health care reform. The groups have sent an open letter to Congress asking for recognition of these facts:

  • Dental conditions become more serious and are more costly to treat without intervention.
  • Untreated dental disease can have fatal and costly consequences.
  • Access to dental insurance is extremely difficult for the nation’s poorest. Half of all states’ Medicaid plans provide no or extremely limited dental coverage.
  • 130 million Americans, including 16 million children and 80 percent of seniors, lack dental insurance coverage. This is more than twice the total number lacking basic health insurance.
  • Poor oral health can complicate diabetes; heart disease; pneumonia; and further study is needed to determine the documented link between gum disease and preterm low birth weight babies.

Having dental insurance can be the difference between simple tooth decay and losing your teeth, or the difference between a toothache and a serious operation. Dental care is preventive care; it saves our hospitals and taxpayers the high cost of treating life-threatening complications and helps poor and middle class people get and keep jobs.

 

Considering a visit to a retail health clinic? – National Consumers League

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Retail health clinics have been popping up all over the United States in recent years. Many consumers find them appealing for their conveniences, but critics question the quality of care and are concerned about their impact on the traditional doctor-patient relationship.

As the United States is facing an increasing shortage of primary care physicians, Americans are turning to other sources of primary care. One delivery model that has attracted growing attention is the retail clinic, which focuses on providing convenient and accessible services at lower, easy-to-understand costs. These clinics are expanding rapidly across the country, from fewer than 100 in 2005 to thousands today.

These clinics are typically located in large retail settings, such as drug stores or big box stores. They are staffed largely by physician assistants or nurse practitioners, who can write prescriptions and have phone access to physicians. The growth of retail health clinics has been limited to parts of the country with legal frameworks that enable such clinics to deliver care and prescribe medication. The care offered through these clinics is restricted to a limited number of generally minor and easily treatable illnesses such as strep throat or urinary tract infections. Retail clinics often provide school and camp physicals, flu shots, and cholesterol checks.

The growth of retail clinics in America has generated debate on how they deliver health care to the consumer. The retail clinic provides convenience to the consumer by with extended weekend hours, central locattions, and fast service with an average wait time of less than 15 minutes – with no appointment necessary. Also many of the clinics post the cost of their services clearly for patients. However, critics argue that there are problems with quality of care due to staffing issues, continuity of care, and there is concern about how the clinics might impact the traditional doctor-patient relationship.

As retail clinics expand, state legislatures have taken a variety of approaches to regulating them. Some states are expanding the scope of practice for nurse practitioners, while others are moving for greater involvement by physicians. A handful of states require that physicians be on-site to support the nurse practitioners. Still other states such as Pennsylvania and California have called for expanding the scope of practice of nurse practitioners, including increased autonomy at retail clinics. Many states have seen bills aimed at additional regulation of clinics. Specifically, a few states have proposed laws restricting clinics by prohibiting the provision of medical services where tobacco is sold.

Given the complexities of the issue, we believe stakeholders will benefit from the opportunity to engage in an open and balanced discussion. NCL has found that multi-stakeholder forums help both consumers and policy makers navigate complex issues. Along with a final report on the forum, NCL will develop consumer education, including factors to consider when visiting a retail clinic. NCL will also summarize the issues state and federal policy makers and regulators should be considering as clinics expand. The report and consumer education pieces will be posted to the NCL website, and NCL will distribute the report to appropriate policy makers.

Thinking about visiting a retail health clinic? Start here with these FAQs

When should I use a retail health clinic?

Retail clinics are designed for providing basic services – cold, flu shot, strep test, etc. Retail clinics are intended for non-emergency and non-urgent use. Often a nurse practitioner or physician assistant provides the care.

Will my health insurance cover my visit to a retail health clinic?

Contact your insurance company to determine if the services are covered BEFORE you go. Ask the retail clinic if there are any other fees. Oftentimes, the fees-for-services are listed as they will be charged, while other times additional procedures might result in additional fees.

How will I know whether a clinic is legitimate?

The Convenient Care Association certifies its member clinics based on a variety of conditions, but not all retail clinics are members of the Association. You have the right to know whether or not a clinic and its practitioners are legitimate. Check to see if the clinic – or at least its practicing providers – are accredited or certified and don’t use their services if the clinic is not certified. Don’t be afraid to inquire about the practitioners’ licensing and certification to ensure that the clinic is legitimate.

What should I tell the retail clinic?

Be sure that you provide whoever cares for you with a detailed medical history – any conditions you may have, medications you may be taking, reactions to medications, past surgeries, history of treatment for disease, allergies, etc.

What should I tell my primary care provider?

Be sure to communicate back to your doctor anything that was prescribed or diagnosed while at the clinic. Get a report form the clinic and take it back to your doctor. And if you take a child, always report back to your pediatrician.

What if I don’t have a primary care provider?

Many of those who visit a retail clinic report that they do not have a primary care provider.

While a retail clinic can provide some basic services when you are in a pinch, it is best to have a primary care provider who knows and understands your entire health history and not just a single condition or ailment.

Common therapeutic drug substitutions – National Consumers League

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Therapeutic substitution, known also as drug switching and therapeutic interchange, is the practice of replacing a patient’s prescription drugs with chemically different drugs that are expected to have the same clinical effect. Many times patients switch to a different drug with no problems. However, for certain medications and conditions, therapeutic substitution could cause problems.

Consumers with a few specific conditions may be more likely than others to encounter a switch. Here are some of the conditions in which therapeutic substitutions may be more common, as well as the concerns about substitution expressed by some patient groups. As always, it is important to talk to your doctor about any potential therapeutic substitution.

In the lists of medicines, the Brand Name comes first, (and generic version is in parentheses).

Antidepressants 
Antidepressants stimulate chemical changes that increase the levels of neurotransmitters in the brain responsible for a person’s mood.

Some examples of antidepressants:
Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa (citalopram), and Lexapro (escitalopram). Antidepressants are associated with drug groups known as MAOIs, tricyclics, and SSRIs and are commonly prescribed by psychiatrists and other physicians to treat depression, bipolar disorder, and other mental illness.

Substitution concerns:
The American Psychiatric Association, Mental Health America, National Alliance on Mental Illness, and the National Council for Community Behavioral Healthcare oppose therapeutic substitution based on the substantial risk of serious adverse outcomes in people with mental illness. These groups support policies that provide patient access to the medications their doctors think they need, and they encourage shared patient-physician decisions based on the unique needs of individuals.

Cardiovascular Medications
There are several classes of drugs used to protect your heart, monitor your cholesterol level and blood pressure, and prevent other damage.

  • ACE inhibitors are used for controlling blood pressure, treating heart failure, preventing stroke, and preventing kidney damage in people with hypertension or diabetes. They also improve survival rates in patients who have had a heart attack.
  • Examples of ACE Inhibitors include: Capoten (captopril), Vasotec (enalapril), Prinivil (lisinopril), Accupril (quinapril) and Univasc (moesxipril)
  • Statins are used to lower cholesterol levels in people at risk of developing heart disease.
  • Examples of statins include: Lipitor, Zocor (simvastatin), Crestor, Pravachol (pravastatin), Mevacor (lovastin).

Substitution concerns:
The American Heart Association and the American College of Cardiology oppose therapeutic substitution and believe that only the prescribing doctor is equipped to determine the best drug or combination of drugs. These organizations believe that therapeutic substitution may result in the patient receiving a drug that doesn’t work well enough, produces life-threatening toxicity, or interacts dangerously with other drugs the patient is taking.

Epileptic medications
The drugs taken by patients with epilepsy are called antiepileptic drugs (AEDs) and are designed to change the electrical signaling in the brain to stop or prevent seizures. 

Examples of AEDs include:
Dilantin (phenytoin), Luminal (phenobarbital), Tegretol (carbamazepine), Neurontin (gabapentin), Lamictal (lamotrigine), Gabitril, Keppra, and Zonegran (zonisamide).

Substitution concerns:
The Epilepsy Foundation is concerned that there are enough differences among AEDs that any kind of medication substitution, (including switching from brand-name to generic), could be dangerous, and it could result in less control over seizures. The Epilepsy Foundation says that changing from one drug formulation to another can usually be done successfully if the patient’s blood levels, seizures, and toxicity are carefully monitored, but it says any medication change must require the permission of the treating doctor and the patient.

Proton-pump Inhibitors
Patients with dyspepsia, peptic ulcer disease, or acid-reflux may be prescribed a proton-pump inhibitor (PPI), drugs that result in long-lasting reduction of gastric acid production.

Examples of PPIs include:
Prilosec (omeprazole), Prevacid (lansoprazole), Nexium.

Substitution concerns:
As with any substitution, it is important to talk to your doctor, and be aware of the benefits and risks of substitution.

What consumers need to know about Rx drug substitution – National Consumers League

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If you take prescription medication, there’s a good chance that someday you’ll be asked to switch from your current drug to a new one. There are many reasons, including costs to you or your insurer, changes in your insurance coverage, or new drugs coming on the market. Therapeutic substitution can offer benefits, but it can also pose risks. The key to ensuring your safety when making a switch is full transparency.

What do we mean by therapeutic substitution?

Here’s an example. Say you have acid reflux and have been taking omeprazole, a proton pump inhibitor to treat it, for several years. Because the cost of another proton pump inhibitor, lansoprazole, is less for your health insurer, your doctor is contacted by your health insurer and asked to switch you to another proton pump inhibitor, lansoprazole, in an effort to save costs.

The availabilty of another drug at a lower cost to your insurance program is one of the top reasons for therapeutic substitution. Among others:

  • Another drug is available to your insurance program at a lower cost.
  • A medication is no longer covered by your insurance program.
  • A cheaper medication is available.
  • You may be offered discount coupons on a different drug, or your doctor may be offered financial incentives for prescribing a particular drug instead of others. This is a practice that concerns some advocates, because it is important that when a switch is considered, your health is always the top priority.
  • Your doctor wants to switch you to a drug that may be more effective or a better fit for your needs.

How does therapeutic substitution happen? There are several ways:

  • Your health insurance company may contact your doctor and urge her to switch from the prescribed drug to another drug in the same therapeutic class.
  • Your health insurance company may contact you, the patient, directly to say you can save money by switching your current prescription drug (a brand name) to a generic version of a different brand name drug. The new recommended drug is in the same class as the one you’re taking, but it’s chemically different. Learn more about drug classes here.
  • Your health insurance company may call or write you to say that your current drug is no longer covered, and you should talk to your doctor about switching you to another drug in the same class that is covered. Otherwise, you’d have to pay out-of-pocket to stick with your current medicine.
  • In some health insurance plans, your doctor and pharmacist all follow the same coverage rules, which include a pre-approved list of drugs. If your doctor prescribes a certain drug that isn’t covered, your pharmacist could substitute it with one that’s on the pre-approved list. In this case, you might not find out that you’ve been switched until you go to the pharmacy.

 

Choosing the right eye care provider – National Consumers League

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Choosing an eye care provider can be confusing! Optometrists, optometrists, opthalmalogists. It is important to understand the differences in education, training, credentials, and experience levels that distinguish one type of eye care provider from another – and what kind of services each specializes in.

Keep this in mind when selecting an eye care provider:

  • Know what your needs are when going to an eye care provider. If you don’t know what you need to have done, ask your primary care doctor.
  • Look for diplomas, licenses, and other qualifications and certifications displayed publicly at the office.
  • Ask the provider is he/she has sufficient training and experience to perform the procedure you need, especially when the procedure is more invasive than a regular office visit.
  • If your eye care needs include surgery or treatment with medications, ask your provider if he or she is trained and licensed to perform these services.  Ask how many times he or she has performed the service, and what kind of side effects and recovery time you can expect.
  • If you do not have access to or are unsure about the eye care provider you need, ask your primary care doctor for a recommendation to properly address your needs. 

What to ask yourself as you consider which eye care provider is right for you

What services do I need my eye-care provider to perform?

You should distinguish between the need for primary care (fitting of glasses and lenses), and more advanced care (serious conditions and diseases, surgery).

State laws and regulations specify what services an eye care provider is permitted to provide. While ophthalmologists, as medical doctors, can perform eye treatments including surgeries and prescribe medications, state laws and regulations vary for optometrists, who are not medical doctors. You should be aware of which services optometrists are authorized to provide in your state, and whether an optometrist is able to provide all aspects of treatment that is needed.

Visit the Association of Regulatory Boards of Optometry for a link to state optometry boards and information on the services an optometrist can provide in your state:

What credentials and qualifications does my eye care provider have?

Check to see whether diplomas, licenses and training credentials are posted clearly in office/waiting room. If this information is not posted, ask the practitioner if he or she is an optometrist (attended optometry school) or an ophthalmologist (attended medical school).

Terms used for eye care professionals can be confusing. For example, some optometrists refer to themselves and other optometrists as “optometric physicians.” Traditionally, only medical doctors or MDs are referred to as physicians. While optometrists offer valuable services, they are not medical doctors, and you should be aware of the difference in training and education.

Does my eye care provider have sufficient training and experience to provide the care I need?

While each member of the eye health care team is a professional with extensive training, you should know whether a provider has adequate training for and experience with the specific procedure or care that you need.

Questions to pose to an eye care provider might include: Is he/she on call if I have a problem at night or on the weekends? If not, who is available to deal with potential problems you might develop? Can he/she provide treatment in a hospital should that be required?

Does my eye care provider have sufficient training and experience performing surgery or prescribing medications?

Ask providers about their surgical training and the number of similar surgeries they have performed before making decisions regarding surgery.  Some questions you should ask include:  Where did they learn the procedure? How many times have they performed the procedure? What is the complication rate (the chance that a problem may occur) for the procedure?  What are the odds of success/failure?

Treatment of eye conditions and diseases often involves using prescription medication. The more prescriptions you receive, the greater your risk of drug interactions. Before prescribing, providers should ask you about other medications you are taking and any other medical conditions you may have. You should keep a personal medication list that includes all prescription medications, over-the-counter drugs (such as aspirin), vitamins and herbal supplements you are taking. Check this list with your provider to make sure there are no complications.

Do I have easy access to the eye care provider I need?

When considering access issues, you need to make sure that, in striving for convenience, you do not sacrifice quality. If you are seeking primary eye care, such as a vision check for glasses or contacts, the nearby optometrists could satisfy your patient care needs. If you are seeking advanced care, such as treatment for serious conditions and diseases, the extra time to access an ophthalmologist is likely worth the assurance of seeing a trained medical doctor.

Do I know how to report problems with my eye care provider to the proper regulatory authorities?

For optometrists, visit the Association of Regulatory Boards of Optometry.

For ophthalmologists, visit the Federation of State Medical Boards.

 

Eye care 101 – National Consumers League

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Consumers have many choices of eye care providers: opticians, optometrists, and ophthalmologists. How do you know which kind of provider is right for your needs?

Eye care providers serve a broad range of patient needs, from fitting eyeglasses to performing invasive surgery, and all have different levels of education and training. Depending on the services you need, one type of provider may be more appropriate than another. In addition to the usual considerations of convenience, cost and established relationship, you should make a point to learn about the credentials, education, training, and experience of all eye care providers.

Meet the members of your eye care team

Here is a listing of the various members of the eye care provider team, what they do and their credentials. Opticians provide the most limited amount of service while ophthalmologists provide all services within the eye care continuum.

Opticians fit eyeglasses and contact lenses, following prescriptions written by optometrists or ophthalmologists. They measure patients’ eyes, recommend eyeglass frames and lenses based on the patient’s needs and can reshape eyeglass frames to fit properly.  When licensed to do so, opticians also can fit contact lenses.

Credentials:

  • They are licensed (required in twenty-one states) after they have earned either an associate opticianry degree (one- to two-year program), or after they have apprenticed for at least two years.
  • They must pass a licensing examination and some apply to the American Board of Opticianry for certification.  Certification is awarded after passing an exam, and must be renewed every three years.
  • In some states, opticians must pass the National Contact Lens Examination to dispense contact lenses.

Optometrists provide routine, primary vision care.They examine eyes to detect vision problems such as nearsightedness, farsightedness and astigmatism, and diagnose eye diseases such as glaucoma. They also test patients’ depth and color perception, as well as their ability to focus and coordinate eye function.  Opticians prescribe eyeglasses and contact lenses, and in some states administer and prescribe medications to help diagnose vision problems and treat certain eye disease.

Credentials:

  • All states require optometrists to be licensed.
  • Optometrists must have a Doctor of Optometry degree that requires a minimum of three years of undergraduate studies at a college or university, followed by four years at an accredited optometry school.
  • They must pass both a written and clinical state optometric board exam in order to receive a license, required by all states.
  • They are regulated at the state level, and must report to a state board of optometry for their license renewal (usually every three years). 

Ophthalmologists are medical doctors who specialize in all aspects of eye health. They provide primary eye care services including eye exams and prescribe medications and perform surgical procedures, such as laser surgery and lens replacement. Using both surgical and non-invasive techniques, ophthalmologists diagnose and manage eye diseases, conditions, and disorders, and treat and repair eye injuries.

Credentials:

  • All states require ophthalmologists to be licensed.
  • Ophthalmologists must have a college degree (or minimum of three years of college), four years of medical school, a one-year internship, and at least three years of an ophthalmology residency (hospital-based training). They must then pass a licensing examination.
  • As medical doctors, ophthalmologists are regulated by state medical boards

Speak the language of your drug coverage plan – National Consumers League

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If you’re facing the opportunity to choose a new drug coverage plan for you and your family, you need to speak the language in order to weigh the costs and benefits.

Brand name (drug): A one-of-a-kind drug that is still protected by a patent.

Co-pay (or co-payment): A fixed amount, for example $10, that an insured individual pays for health services, regardless of the actual cost of that service.

Co-insurance: A percentage of the cost of a health service, usually 20%, paid by the insured individual.

Deductible: An amount an insured individual must pay for health services before their insurance plan begins to pay any benefits. For example, the individual may be required to pay the first $500 before the insurance company will pay for subsequent services.

Formulary:A list established by a health plan or PBM to indicate which drugs they cover or which tier drugs are in.

Generic drug: A drug that is no longer patent protected, so that many companies can copy and manufacture the drug with the same active ingredient as the original inventor.

Mail Order: Prescriptions that are received in the mail.

Out-of-Pocket Maximum: An upper limit on how much an individual or family must pay in a year for health services. Once the limit is reached, co-insurance and sometimes co-payments do not have to be paid.

OTC Drugs: Over-the-counter (OTC) drugs can be purchased without a prescription and are generally not covered by insurance.

Pharmacy Benefit Manager (PBM): A company that administers a pharmacy benefit plan. They aren’t insurance companies; but are often subcontracted by health insurers or employers to manage the prescription drug portion of the health plan.

Prior authorization:A requirement that a physician obtains approval from the health plan or PBM in order to get the medicine covered.

Step therapy: A requirement of the health plan or PBM to try a less expensive drug first. If that drug fails to work on the patient, the health plan or PBM will then approve the use of a more expensive drug.

Therapeutic substitution: The process of switching an existing prescription to one that is less expensive and chemically different, but has the same expected clinical effect.

Tiered co-pay (co-payments): A co-payment that is determined by which tier the drug is assigned to by the health plan or PBM. There may be a few tiers, each with a different co-payment amount. This design is intended to encourage the use of drugs that are in the less expensive tiers.

Questions for choosing an Rx drug plan – National Consumers League

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Before you decide on a prescription drug benefit plan, get the facts you need.

1. Will I be able to get the medicine that my doctor and I think is best for me?

Find out if the health plan or PBM has a limited list of medicines it will cover (known as a formulary). If someone in your family takes medication for a chronic illness, such as high blood pressure, asthma, or high cholesterol, make sure that medicine is on the formulary before you select that plan. If it isn’t, and you choose that plan, you will be expected to switch to a different medication or pay for it out-of-pocket. This is a discussion you should have with your doctor — to make sure you are taking the drug that is best for you.

Find out if the health plan has to pre-approve certain medicines before you can fill the prescription. Many plans require your doctor to get “prior authorization” of high cost medications before you can get coverage for them. That means your doctor or pharmacist must call the health plan or PBM for permission to give you a prescription for these medications. Some plans also require you to try a less expensive medicine first — before they will cover the one your doctor recommends. Check with your plan to understand their authorization process and restrictions to avoid a surprise when you get to the pharmacy. And be sure to learn how to appeal these requirements and decisions if you feel it is important.

Find out how often your health plan or PBM changes its formulary. Be aware that, in most states, even though your medications may be covered at the time you choose your health plan, the health plan or PBM may change its list of approved medicines at any time throughout the year. If they choose to take your medication off the formulary, you will be expected to pay out-of-pocket or switch to a medication the health plan prefers. Check to see what sort of notification you will get so you can discuss changes with your doctor.

2. How much will I have to pay for my prescriptions?

Find out about the co-payments. Most plans require you to pay a co-payment for each prescription. Some plans have just one co-pay amount, for example $10.00, for any prescription. But many plans have different levels of co-payments (known as tiered co-pays) for different medicines. If the plan you are considering has tiers, you should find out what medicines are in each tier and what the co-pay amount is for each. Note that the health plans and PBMs can move your medication from one tier to another at any time. If the amount you will have to pay is more than you can afford because your medication is in the highest tier, you may want to ask your doctor if there are other drugs on a lower tier that is appropriate for you. Also ask about how you will be notified if your plan makes tier changes.

Find out if there is a limit on how much you have to pay each year. Many health plans try to protect individuals from catastrophic costs by having “out-of-pocket limits.” You don’t have to pay co-insurance on medical services once you reach that limit. But prescription medications are often not included in the protection. So you may still have to pay your co-payments for medicines even after you reach the out-of-pocket limit.

Find out if the health plan offers or requires you to get your medicines through a mail order service. 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 order services and require you to order your long-term medications through the mail. The plan will not pay for them if you get them at a local pharmacy.

3. Does the health plan allow me to appeal for coverage of prescriptions they have denied?

Find out about any exceptions or appeal processes offered by the health plan or PBM. If you really need a medication because of a valid medical reason, you can often get it covered. But you must go through whatever exception or appeal process the plan may have, and they have to agree that you really need the medication you want, based on information your doctor will be expected to provide. If you can’t wait for the process to finish, you may need to pay for the drug yourself and then file an appeal to be reimbursed by the plan later.

You should be aware that you will not be notified of your right to appeal when you are denied coverage because your medication isn’t on the formulary. So you must become familiar with how to file an appeal on your own initiative.

You should also know that most plans do not allow you to appeal for a lower co-pay level, even if the only medication that works for you is in the most expensive tier.

Get the answers!

The following resources can help you get answers to these questions:

  • Materials that the health plans or PBMs give you
  • The Web site for the health plan or PBM (look for general benefit information and plan requirements, as well as information on their current formulary)
  • A sales representative from the plan (they are often available at your worksite during the time of year when you must make decisions about your plan for the coming year)
  • The benefits department in your employer’s human resources division
  • The state Department of Insurance or, if your state has one, the Managed Care Ombudsman