By Lisa Zamosky
Prescription drugs can be a major cost for people with on-going health conditions, especially for people being treated for conditions such as cancer, hepatitis C, diabetes, and multiple sclerosis. New drugs to treat rare and complex conditions are becoming more expensive. At the same time, the health plans sold through the insurance Marketplaces often come with high out-of-pocket costs that leave people who need specialty prescription drugs shouldering more of the expense.
If you rely on medications to manage a chronic or complex condition, here are 4 steps to take to make sure you’re getting the most of your health plan’s drug benefit.
1. Review your plan’s formulary. Your health plan’s formulary, or list of covered drugs, will tell you whether the medication your doctor prescribes is covered by your plan. Often, insurers post this list online, but frequently the list is incomplete, so you always want to check directly with your plan.
With specialty drugs you have less flexibility to switch to another option if the one you’re prescribed isn’t covered by your insurer. Still, checking before you go to the pharmacy gives you the opportunity to discuss it with your doctor. After all, medications don’t work if you can’t afford to buy them.
2. Know your plan’s guidelines. To get the most out of your health plan benefits, you must always be mindful of the rules you must follow before going for care or filling a prescription.
Common requirements include getting prior authorization from your plan to get help paying for a medication you need. In addition, many plans today require you to try a less expensive, generic drug (if one exists) before approving name-brand medications. Quantity limits that allow you to buy only a small amount of the medication at one time also are common.
3. Check your plan’s medical benefits. Specialty drugs, such as those used to treat cancer, are often delivered to your doctor’s office rather than to your home. In that case, check your plan’s medical benefit, rather than the drug formulary, to see what’s covered.
4. Remember your right to appeal. The Affordable Care Act guarantees you the right to several levels of appeals if your insurance company denies coverage for a medication or medical service you need. Often, consumers are successful when they take the time to appeal. If your insurer says it doesn’t cover a drug, get your doctor’s help in explaining to your insurer why it’s important for your health.
Have your medication costs gone up? Please share your experience in the comments section below.