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Knowing the Rules: Consumers Must Understand Health Plan Rules to Ensure Uninterrupted Access to Needed Medications

Advice to Help Consumers Get What They Need from their Prescription Drug Benefit

WASHINGTON, D.C. – The new plan year often brings a change to health insurance plans and the rules that go along with them. For consumers becoming familiar with new plans and seniors starting to use their Medicare prescription drug benefit, this may mean trouble when filling prescriptions for the first time.

But even those who are continuing on with the same plan as last year may experience some of the same frustrations. Rules can vary from health insurance plan to health insurance plan and even from one pharmacy visit to the next because plans are allowed to make changes throughout the year. And consumers may not be aware of issues that may impact copayments and lists of preferred medicines, thus causing problems when trying to fill a prescription.

In an effort to help consumers to become educated and prepared, eleven groups representing consumers, pharmacy, physicians, patients and pharmaceutical companies have teamed up to provide free tips and resources to help consumers understand how prescription drug benefits work and find out what to do if coverage for their medicine is denied. The program offers guidance for navigating drug coverage, tips for troubleshooting problems, and a sample appeal letter and a glossary of important terms, available at www.YourPharmacyBenefit.org.

"Pharmacists can be a patient's greatest ally in navigating new drug coverage programs," said Mary Ann Wagner, the senior vice-president for pharmacy, policy and regulatory affairs at the National Association of Chain Drug Stores. "They are highly trained and thoroughly familiar with patients and their medicines. The resources offered by www.YourPharmacyBenefit.org are more valuable tools for helping patients make sure their healthcare needs are met."

The program offers several tips to help consumers who encounter problems filling a prescription, including situations where:

• The information your pharmacy has about your plan doesn’t match what is on your pharmacy benefit ID card.
• It’s too early to refill the prescription.
• A particular medication may react badly with another medication you’re on or with another medical condition you have.
• The medicine your doctor prescribed requires your plan’s prior approval.
• The medication is not covered by your health plan, or is not on the “formulary,” the list of medicines covered by the plan.

The Web resource explains all of these situations and provides tips on how to resolve these problems. It also provides other important information including how to understand “insurance-speak,” and who to contact when questions arise. It also explains to consumers how to file an appeal if the plan refuses to cover a medicine the patient needs.

"Consumers will find this site helpful in giving them information about how prescription drug coverage works so they can ensure their medicines are accessible and affordable,” said Gary A. Puckrein, PhD, Executive Director, National Minority Health Month Foundation. “Nobody wants to be surprised by having to pay out of pocket for a prescription they thought their insurance would cover."