Choosing a prescription drug coverage plan – National Consumers League

/in /by

When choosing a health plan, making sure the medicines you take regularly are covered is just as important as knowing 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 PBM.

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

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, such as 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 be expected to switch to different medications or pay for them without insurance.

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 that they 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 a co-payment for each prescription. Many plans 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 less expensive medicine before it will pay for the one your doctor might otherwise recommend. 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 order 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.

When choosing a health plan, making sure the medicines you take regularly are covered is just as important as knowing that your doctor is in the network. Knowing how to select the right prescription drug coverage for you and your family is important to maintaining and restoring your health.

While most insurance includes coverage for prescription medicines, the rules for pharmacy benefits are often different than for medical. For example, your prescription claims may be handled by a pharmacy benefit manager, or PBM (a company that administers a health plan or employer’s drug benefits).

Asking the right questions is key to getting the most appropriate medicines for you and your family and in limiting your costs. When making decisions, always look at the potential impact of your health plan choice on the medicines that members of your family are currently taking for a serious condition or chronic illness.

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

Health IT: growing interests and concerns – National Consumers League

/in /by

Many assume that the health care system in the United States is the best in the world — at least for those who are able to access it. The reality for many people is that our system often fails to deliver quality care, misses many people who need care the most, and suffers from significant inefficiencies that lead to high costs. Even according to conservative estimates, hospital errors are the nation’s eighth leading cause of death — ahead of breast cancer, AIDS and motor vehicle accidents combined.

Preventable medical errors include a wide variety of examples: misidentification of patients; misreading of tests; medication errors, equipment failures; and hospital-acquired infections. Researchers have estimated that your chance of getting the right care at the right time is only slightly more than 50 percent — and it’s worse for women and minorities!

Unfortunately, low-quality health care means high-priced consequences. The combination of overuse, misuse, and underuse accounts for up to 30 percent of our national health care expenditures. Improving the quality of care would make Americans healthier and help us address the skyrocketing costs. With that goal in mind, many policy makers, businesses, health care providers, and provider institutions (such as hospitals) are looking to health information technology (HIT) as a way to improve health care quality.

HIT represents a transition from paper-based to computer-based transactions for health care services. For patients, it can mean that doctors use computers to keep track of patient health information, rather than traditional paper charts. These electronic medical records can help health care providers stay organized and make better clinical decisions. Much of the real value to patients and providers is seen only when multiple providers (and ideally the patient) are able to share medical information electronically whenever and wherever it is needed. This concept is often referred to as health information exchange, or HIE.

Appropriately implemented, HIE has the potential to provide consumers with information to make better decisions about their own health care and the care of their loved ones. An electronic health record that could be accessed by authorized parties would mean that health care providers would be able to access the information they need (medications, lab results, allergies) to make better health care decisions.

While all of this is possible, there are potential risks. Understandably, many consumers are afraid that broader sharing of their personal health information will only make it more vulnerable to unwanted and unintended exposure, which could have significant life-long consequences for their personal, social, and financial wellbeing. While NCL is very supportive of moving forward with health information technology and exchange systems, these initiatives will only succeed if all consumers can be confident that their personal health information is being handled in a secure, appropriate, and confidential manner.

NCL is part of a growing consumer coalition dedicated to seeing that these and other essential conditions are built in to systems emerging across the country. This is a critical time for consumer involvement, as efforts to promote nationwide adoption of health information technology are proceeding rapidly. There is a significant need for strong consumer voices at all levels of this effort — voices that strongly support the promise of health information technology to improve our healthcare system, but that will work to ensure adequate consumer protections. 

 

Trends in medicine: What is evidence-based medicine? – National Consumers League

/in , /by

Doctors and health care professionals are attempting to help patients make sense of the overload of health information by gathering, evaluating, and sharing well–tested, proven medical research. This process of bringing the best available evidence from scientific research to patient care is known as evidence-based medicine (EBM).

The emphasis with EBM is on applying research to medical care: when there is evidence that a treatment works and benefits the patient, it is practiced; where there is evidence that a treatment has not benefited the patient, is ineffective, or harmful, it is not practiced; and where there is not enough evidence, healthcare professionals should proceed carefully.

Many patients are educating themselves about their health, self-diagnosing, and pursuing care on their own.

Some patients are using health information to self-diagnose their conditions and asking doctors to prescribe treatments based on their own research, others are confused by the overload of health information.  To improve health outcomes, doctors and patients should share the responsibility for making health care decisions.

  • Patients are bringing in articles and ads and self-diagnosing specific conditions. This presents an opportunity for doctors and patients to discuss the patient’s actual situation and make appropriate decisions based on shared information.
    • Pharmaceutical ads are a major source of tension because they tell patients to ask the doctor for certain prescriptions by name without knowing if it’s appropriate. Doctors should take the time to explain to patients why the drug is or is not appropriate for them and then discuss other treatment options as well.
  • Doctors can start the dialogue to help patients sort out their questions and concerns.
  • Learning about medical treatments from friends, family and co-workers is a significant source of information that is credible to patients.
  • Often times, patients feel they know what is wrong before seeing a doctor and the challenge is communicating this knowledge to the doctor.
  • Doctors who disagree with their patients’ diagnosis or do not provide them with the desired treatment are often criticized. Shared decision making helps avoid disagreements and leads to successful patient outcomes.

All of the health information now available to consumers is changing the patient/doctor relationship.

Patients’ increased access to medical information is changing the relationship between patient and health care professional.

  • Patients have access to more medical information than ever before through magazine articles, advertisements and online searches, and health care professionals can play a critical role in helping patients differentiate the good from the bad.
  • More patients are taking more responsibility for their own care and want doctors to be partners, not bosses, in this relationship.
  • As America becomes more diverse, we need to pay special attention to cultural, linguistic, and economic barriers that may inhibit consumers from getting the information they need to make appropriate health care decisions.

To help doctors and patients make treatment decisions, it is necessary to sort through health information and find the best medical treatment based on what has been proven to work and is effective

Many doctors and other health care professionals are attempting to help patients make sense of the overload of health information by gathering, evaluating, and sharing well-tested, proven, medical research.  With this research, the health care professional and patient make treatment decisions together based on what works and is effective.

  • Health care systems are working towards a decision-making process incorporating medical research evaluation along with good stewardship – if there is evidence a treatment works and benefits the patient, it is practiced; if there is evidence a treatment has no benefit or may harm the patient, it is not done.  In cases where there is insufficient evidence about a treatment or if evidence doesn’t exist, a consensus is developed among health care professionals and they proceed carefully.  It is a shared decision-making process between patient and doctor.
  • Your doctor uses clinical judgment, incorporating the best research, his/her knowledge and experience, to present you with treatment options.
  • Making decisions based on what has been proven to work helps ensure that you and your health professional choose the most effective and beneficial treatment for you.  Understanding what works most effectively helps spend your health care resources wisely and benefits everyone.

Ask your doctor or other health care professional about how you can decide together what is the best medical treatment for you.

Patients and doctors need to engage in a dialogue about making the best medical treatment decisions.

  • Health care providers are working at bringing together the best available information about health care practices to create and implement programs that help people live healthier lives.
  • Health care providers have created specific care management programs for many diseases, including diabetes, asthma, congestive heart failure, coronary artery disease and depression.
    • Health care professionals stay up-to-date by using a computer system of well-tested medical research that can be used right in your doctor’s office.

Additional Resources about Evidence Based Medicine

To learn more about making health care decisions based on the best medical evidence, check the following resources for quality health information:

Cochrane Consumer Network.  This Web site is part of the Cochrane Collaboration, an international organization that aims to review all healthcare evidence and publishes the reviews electronically. The consumer network website summarizes the reviews for consumers.

MEDLINEplus at www.medlineplus.gov has extensive health information for consumers from the National Library of Medicine and the National Institutes of Health.

The National Committee for Quality Assurance (NCQA) consumer Web site at www.healthchoices.org explains how to choose a health plan based on quality. Includes a Health Plan Report Card.

Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) website at www.jcaho.org has information on the quality of care at your local health care facility.  JCAHO evaluates the quality and safety of care for health care organizations.

Kaiser Permanente’s Care Management Institute, www.kpcmi.org, establishes care management programs for patients based on the best available evidence.

To learn more about evidence-based health care and how healthcare professionals are making treatment decisions, Check out the online course developed by CUE (Consumers United for Evidence Based Health Care) on Understanding Evidence Based Healthcare: A Foundation for Action.

About this Web page

These messages were developed by the NCL, in partnership with Kaiser Permanente, to educate consumers about the concept of Evidence-Based Medicine. For more information, contact NCL’s health policy team.