Understanding Prescription
Benefits
by Glen Pietrandoni, R.Ph.
For people living with
HIV/AIDS, prescription drug benefits are an important part
of care necessary for success of any treatment regimen. Drugs
must be affordable, accessible, and available without interruption.
As a community pharmacist, I get lots of questions about insurance
coverage. Believe me when I say it is confusing to providers
as well as the patients! Let’s try to sort out some of the
facts.
Because the insurance industry,
Medicaid, Medicare, AIDS Drug Assistance Programs (ADAP) and
Social Security are all regulated by state or federal government
agencies, there are variations on benefits and restrictions
from one state to another. For example, an ADAP program in
State A may may only pay for antiretrovirals, while State
B also allows drugs for opportunistic infections, lipodystrophy,
and lipid control.
Prescription drug benefits
given by employers are the most complicated. In general, the
pharmacy portion of health insurance provided by employers
is a small part of an entire package of benefits. For the
majority of the public who may only need a couple of prescriptions
filled a year, medications are not a big priority. Those living
with HIV/AIDS need at least five or six prescriptions every
month. You are usually locked into a program for a year, or
until there is an “open enrollment” opportunity to change
policies. It is important to understand your plan so there
are no surprises at the pharmacy.
Co-pay
is the amount that the patient must pay for each prescription.
It is usually a fixed dollar amount. Sometimes there are two
co-pays: a higher one for brand name drugs, and a lower price
for generic drugs. Co-pays must be paid at the time the prescriptions
are picked up. These co-pay fees are slowly getting higher
and higher. It is not unusual to see a $30 co-pay on each
prescription. With many prescriptions a month, it really adds
up. Some policies have percentage co-pays rather than a fixed
amount, usually 10% or 20%.
Formulary plans
only allow you to get certain drugs using your insurance;
other drugs would have to be purchased at the full price.
At this time, I know of no formulary plan that excludes any
antiretroviral, but I have seen these plans exclude drugs
for other conditions such as opportunistic infections and
depression. A list of drugs covered by insurance is provided
when you enroll. Ask your doctor to look over the drug list.
Keep a copy of it in your medical records and give one to
the physician so that it can be used when prescribing new
drugs. This will save you (and me) a lot of time and aggravation
at the pharmacy. Providers writing prescriptions for those
with HIV/AIDS have to be concerned about drug interaction
with the antiretrovirals, especially the protease inhibitors.
The “recommended” drug that is offered on the formulary may
not be the correct choice for you, requiring you to pay the
full retail price for the best choice.
Mail order
options are offered to
patients receiving “maintenance drugs” or drugs that are needed
for long periods of time, as opposed to prescriptions that
are needed and used immediately. This can save money because
of lower co-pay amounts. The drawback is that you have to
be organized to plan ahead to place orders and have refills
placed by the physician. This option does not allow for face-to-face
consultations with the pharmacist, but a pharmacist can be
contacted through a tollfree telephone number.
Most prescriptions
are filled for 30 days, with a couple of days leeway. Some
insurance companies are very strict about allowing early
refills, as when planning a vacation. Mail order prescription
plans allow for 90 days of supply to be dispensed for fixed
co-pays.
When drugs are “not covered”
by an insurance company, a prior authorization can
be obtained to by-pass this ruling. This usually requires
the physician to write a letter or submit a form to the insurance
company to explain the need for the drug. It usually takes
a few days to even weeks to get this accomplished.
Some policies specifically
exclude injectable drugs. Testosterone, human growth
hormone, and maybe the new fusion inhibitors could possibly
be excluded under this restriction.
Under limited access,
you may be required to use only certain pharmacies to obtain
refills.
Discount plans
are not a good option for HIV-positive patients. Instead of
paying the full retail for a three-drug regimen of about $1,000,
the discount may only be 10%, leaving $900 still due from
you.
Reimbursement plans
could be a problem as well. Even though the insurance company
may pay 80% for example, it requires the patient to pay the
total pharmacy bill up front and wait for the insurance company
to send a check. Some pharmacies may agree to take an assignment
of benefits. The pharmacy will charge the patient the
deductible (20% in this example) and then will wait for the
check to be sent directly to the pharmacy from the insurance
company. Pharmacies can charge vastly different prices under
this plan, so do your shopping!
Glen Pietrandoni is
director of Clinical Pharmacy Services for the Walgreen Specialty
Pharmacy, focusing on HIV, located in the Howard Brown Health
Center of Chicago.
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