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