Prescription Drug Benefits in Managed Care
By: Source: AARP.org Date Posted: 2003-05-08 15:55:00-04:00
Many managed care plans have a prescription drug benefit. However, because prescription drugs can be very expensive, many plans place limits on what they will pay. Some plans limit how much they will pay each year or have you pay different copayments for different drugs. A copayment is the set amount you pay for each drug or medical service. Some plans only pay for generic drugs.
Most plans also control their prescription drug costs by using "formularies" or "preferred drug lists." Check with your plan's member services department to find out if your plan uses a formulary, which drugs it will and will not pay for, if there is a yearly limit on prescription drug benefits, and how much that limit is. Get a copy of the formulary and find out how often it can change.
Formularies/Preferred Drug Lists
Formularies or preferred drug lists are lists of preferred or recommended medications. These are the medicines that the health plan encourages its doctors to prescribe. Here is some information you should know:
- Many formularies or preferred drug lists are designed to encourage patients to ask for generic drugs which can be substituted for brand-name drugs. Generic drugs are chemically equivalent to brand name drugs, but they cost much less. Many plans have lower copayments for generic drugs.
- Some plans use a "managed" formulary, in which the plan pays for almost all drugs, but has lower copayments for "preferred" drugs than for "non-preferred" drugs.
- Other plans allow doctors to prescribe only drugs that are on their lists and rarely pay for drugs that are not on the lists.
- Your doctor might need to get the plan's approval before writing prescriptions for drugs not on the plan's list. You might need to pay the entire cost of the medicine if your doctor does not get an okay before writing the prescription.
Ask your doctor to first check the prescription to make sure it is on the plan's formulary or if it is a "preferred" drug. If it isn't, ask your doctor if there is a formulary or preferred drug that would be just as good for you. This can save money for you and your plan. If your plan will not cover the cost of the medicine, you may be able to appeal. Make sure you know your plan's rules for seeking an appeal.
You should always ask your doctor about whether the drug on your plan's formulary or preferred drug list is right for you. Your pharmacist may also be able to give you information about different kinds of drugs. You can get information on the best drugs to treat certain conditions from the Oregon Prescription Drug Guide.
Mail-Order Pharmacy Services
Many managed care plans let you get your medication from mail-order pharmacies. In fact, in some plans you must get your medication from a mail-order pharmacy if you take the same medication for a long time for conditions such as asthma or diabetes.
Mail-order pharmacies have toll-free numbers that you or your doctor can call with the prescription. You then get your medication in the mail, rather than from the pharmacy. It might cost you less to get your medication through mail order and may be more convenient. Call your plan's member services department for more information.
AARP Resources
Wise Use of Prescription Drugs
What you should know about prescription drugs.
Oregon Prescription Drug Guide
Information about drugs that have been found to be most effective for medical conditions such as arthritis pain, high cholesterol, chronic pain and heartburn.
State-by-State, Plan-by-Plan List of Pharmacy Assistance Programs
Prescription discount programs offered by states, drug makers, discount cards and discount pharmacies.
How to Be Drug Smart
Expert advice from some of the nation's top doctors on how to get the most from your medicines-and save money.
Additional Resources
U.S. Food and Drug Administration
Frequently asked questions and a series of articles about prescription drugs.
http://www.fda.gov/cder/about/faq/default.htm
http://www.fda.gov/cder/consumerinfo/DPAdefault.htm
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