Boost Your Rx Plan IQ!
Boost Your Rx Plan IQ!
(ARA)- About 75 percent of all Americans already have some type of prescription drug plan. When the Medicare drug plan begins in 2006, millions more will receive a drug plan for the first time. The Academy of Managed Care Pharmacy wants to help you learn some important drug plan words. How many answers do you know?
* What is a covered drug? If a drug is "covered," that means the plan will pay a part of the cost.
* What's a co-payment? A co-payment, or co-pay, is the amount of the drug cost that you pay for. A co-pay for a brand name drug may be $15, $25 or more. A co-pay for a generic drug may be as little as $3.
* What's co-insurance? Co-insurance works like a co-payment, but it's a percent of the drug cost instead of a set price. So, if a drug costs $100 and you have 30 percent co-insurance, you pay $30 and your plan pays $70.
* What's a drug formulary? The list of drugs covered by your drug plan is called a formulary (FOR-mew-lerr-ee). It's developed by medical and pharmacy experts. Ask your drug plan for a copy of their formulary, or the plan's Web site address, and give that information to your doctor. If the drugs you take are not included in the formulary, ask your doctor or pharmacist about other choices.
* What's a tier? Drugs on a formulary are usually divided into groups called tiers. Most plans have three tiers: generics, preferred and non-preferred. Your share of the cost varies depending upon which tier it's in. Usually, generics are the least expensive, and non-preferred drugs are the most expensive.
* What's a PBM or a PDP? A "PBM" is a "Pharmacy Benefit Manager." A "PDP" is a "Prescription Drug Plan." These companies manage drug plans for the employer or government agency that pays for your plan. PBMs and PDPs provide many services, evaluating drugs, monitoring care and keeping expenses down to ensure drug costs stay affordable.
* What's a prior authorization (PA)? Some prescription drugs are dangerous if taken by children, older people or pregnant women. Others require careful monitoring, are very expensive, or may have been prescribed for a purpose different than the purpose for which it has been approved. In any of these cases, your plan might require a PA to cover it.
* What's an exception? If a drug your doctor prescribes is not in your plan's formulary, you or your doctor can ask for an exception, explaining that the drug is medically necessary for you.
* What's an appeal? If your request for an exception or a PA is turned down, you have the right to appeal. An appeal is a formal process to determine whether or not the drug will be covered. If your plan won't cover the cost, that doesn't mean you can't get the drug--it only means your plan won't pay for it.
If you knew the answers to these questions, you are well on your way to choosing and managing a drug plan wisely. If not, clip this column and keep it for handy reference.
For more information about the Academy of Managed Care Pharmacy, visit www.amcp.org.
Courtesy of ARA Content