Jayne O'Donnell
Premiums and deductibles tend to get the most attention when it comes to health insurance. Drug coverage deserves far more than it gets. And that's true whether you're shopping for insurance on one of the new health care exchanges or dealing with open enrollment at your employer.
Many people may not visit their doctor too often, but prescription drugs are often what's keeping them alive. About 22% of American are taking three or more prescription drugs, and 11% are taking five or more, according to a study by the Centers for Disease Control and Prevention.
A provision in the new health law that should be of special interest to those taking many, or at least, pricey pills is a new limit on out-of-pocket costs — and it includes co-pays and other prescription drug costs. This limit, which takes effect Jan. 1, is about $6,000 for individuals and $12,000 for families. If you're on an expensive specialty drug for a serious or chronic condition, this could be especially good news, as these drugs could total as much at $100,000 a year for some patients.
The not-so-good news: This applies to all but what's known as "grandfathered plans," which were in place before the law took effect in 2010. (According to the Kaiser Family Foundation, about 36% of plans this year are grandfathered. If an insurer or employer makes significant changes to a plan's benefits or how much members pay through premiums, co-pays or deductibles, plans lose their grandfathered status. Not sure if yours is? Kaiser recommends calling your insurance company or your employer's human resources department.)
Many people with employer-provided plans may find their deductibles are much higher this year, which may make this change seem like small consolation, but it will come in handy for those who take multiple medications.
Whatever plan you buy insurance from should have what's known as an "accumulator" that tracks all your out-of-pocket medical and pharmacy costs, says Ellen Nelson, senior vice president of government relations at Catamaran, a pharmacy benefit manager that works with insurance companies and employers.This information would be reported to you.
"This is an attempt at least to keep people out of going bankrupt over medical expenses." Nelson says. "We're all waiting to see the impact."
Plans on the new state and federal exchanges are grouped by bronze, silver, gold and platinum, depending on how much consumers have to pay out of pocket (with platinum being the least, at just 10%). Those considering silver plans on the new exchanges may find their drug costs are likely to be greater, and for some expensive drugs, they are more likely to hit the deductible, says Eric Johnson, a marketing professor at Columbia University who's been studying the affordability of the exchange plans.
"This is a especially difficult problem unless someone does the math, because they are trading off deductible costs, vs. out-of-pocket costs, vs. premiums," Johnson says. "If someone starts to need a new expensive drug during a year, they may have made a bad choice."
Here are key steps in smart pharmacy benefit shopping:
1. Talk to your doctor about the medications you're on, whether they are truly needed and if there's a cheaper alternative that would work for you, says Susan Gaca, chief nursing officer at Cigna Insurance.
2. Review the drug formulary — the list of drugs it covers — when considering different insurance plans. Plans will try to steer you to the lowest-cost alternative. At Cigna, for example, a prescription to the cholesterol-lowering drug Lipitor on one plan could cost a consumer $150 out of pocket, but the generic equivalent would be free. If there is no generic available, there is often a preferred brand, which has a lower co-payment, and a non-preferred brand, Gaca says.
There are typically at least two drugs offered for each class of drugs, Nelson says, and which ones are offered depends on a benchmark plan established by the state. One plan might have acid reflux drug Prilosec on its formulary, while another might have Nexium, she notes.
3. Make a list of the drugs you (and any family members) need to continue taking, the number of prescriptions you need a year and track what they — or their generic or lower-cost alternative — would cost on the different plans you are considering.
4. Check if there's a mail-order option. If there's a drug you need, say, a 90-day supply, Nelson says you can probably get it by mail for two co-payments rather than three. Although every plan is different, she notes "maintenance medications" frequently do have a mail-order plan.
5. Can't afford the drugs you really need? Check with your plan's pharmacy benefits manager to get referrals to public or pharmaceutical company sources that may provide drugs for free.
Or maybe you're one of the lucky ones and don't need any drugs now. Just wait. If you cut corners too much on your choice of plan and pharmacy benefits, you may be in for a financial surprise.
"If someone starts to need a new expensive drug during a year, they may have made a bad choice," Johnson says.
Source: USA Today
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