“Formularies, specialty tiers, prior authorization — health insurance might as well be written in another language,” explains Terry Wilcox, co-founder and executive director of Patients Rising, a national patient advocacy non-profit organization that helps patients overcome insurance barriers to access.
She adds, “Insurance companies and pharmacy benefit managers have turned open enrollment into an extremely stressful and anxiety-inducing process for patients, especially patients living with chronic conditions and rare diseases.”
That’s because insurance barriers, such as step therapy, prior authorization and specialty tiers, can block patients living with chronic conditions from accessing the treatments prescribed by their doctor.
Open enrollment for 2020 health care coverage is from November 1, 2019 to December 15, 2019. Whether you are looking for Medigap, Medicare, short-term plans or marketplace plans, here’s what every patient should look for during open enrollment.
Insurance Barrier: Step Therapy
What It Is: Step therapy is an insurance policy that requires patients to fail first on a cheaper and less effective drug that will boost PBM and insurance profits.
Who Should Beware: Migraine Patients
Every patient living with migraine experiences a different set of triggers and unique symptoms. You can spend months working with your doctor to get the right treatment in the right dosage. Insurance companies can undermine a migraine patient’s treatment plan by imposing step therapy requirements. After all of that time figuring out the right treatment, a new insurance year can mean starting all over again with a cheaper substitute drug.
Patients Rising’s Recommendation: Check the Drug Formulary for “ST”
Thoroughly review the insurance drug formulary, the list of treatments that your insurance will cover. Search the drug formulary for your prescriptions. If you see “ST“, that means your insurance requires you to go through step therapy first.
Take Action: Support Step Therapy Reform in Your State
Patients Rising NOW is working throughout the country to support step therapy reform legislation, including H.1853/S.1235 in Massachusetts.
PBM Barrier: Prior Authorization
What It Is: Prior authorization requirements force patients to get permission from the insurance company or pharmacy benefit manager before insurance will agree to cover your treatment.
Who Should Beware: Patients living with Arthritis
Patients living with different types of arthritis, especially osteoarthritis and rheumatoid arthritis, frequently face prior authorization requirements from their insurance company. According to a recent study from Massachusetts General Hospital in Boston, arthritis patients under prior authorization policies waited twice as long for care and saw their corticosteroid exposure double.
Patients Rising’s Recommendation: Don’t Automatically Re-Enroll in the Same Plan.
Always take the time to review your plan’s drug formulary for coverage changes. PBMs and insurance companies change policies from year to year, and may have added a prior authorization requirement, which is sometimes indicated by a “PA” next to the drug. New plans might be a better option for you.
“To get an expensive drug covered you may first have to try a similar one, or have your doctor prove you need it, and that can take weeks,” writes Lacie Glover, a writer at the personal finance website, NerdWallet. “Even if you’re not facing such a situation right now, take a few minutes to learn about how drug formularies work.”
Take Action: Share Your Story with Patients Rising NOW
Insurance Open Enrollment Scheme: Specialty Tiers & Higher Out-of-Pocket Costs
What It Is: Every year, PBMs work with insurance companies to identify ways to change their formularies to boost insurance profits. This can include shifting a drug to a higher specialty tier, which will mean higher out-of-pocket costs every time you fill your prescription.
Insurance companies routinely move treatments for diabetes, lupus, and chronic pain to specialty tiers. Pharmacy benefit managers make billions of dollars in profit from obscure changes to drug formularies.
Patients Rising’s Recommendation: Identify Your Drug Tier & Actual Co-Pay
Make sure your medications for diabetes, lupus, or chronic pain are covered on your insurance plan’s formulary. If your medication isn’t listed, it’s not covered.
“Make sure your medications are on your plan’s formulary and look at what the quantity limits are,” Elizabeth Gavino, founder of Lewin & Gavino in New York, told CNBC. “Each carrier has their own limits and it might be less than what you need — say they only allow 30 pills monthly, but you need 60.”
There’s no guarantee that your insurance will cover the same treatment from last year at the same co-pay level. Identify your drug’s tier and calculate the out-of-pocket costs. Identify the plan’s medication limits. Your medication might be covered but not in the quantity that you need. Or, you may be required to fill the prescription through specific pharmacies.