By Patricia Prewitt
My Personal Rx Adviser
I recently saw a notice that several prescription benefits companies are no longer covering newer diabetes medications as of July 1. Insurers can issue mid-year formulary changes that may impact your prescription coverage. Mid-year changes can be quite confusing for both patients and providers.
What are mid-year formulary changes from a prescription benefits plan?
Some prescription benefits companies will implement changes during any given year to their drug formulary coverage list. If you are a consumer who carefully chose your plan at the beginning of the year, it can be quite frustrating to receive a notice that your prescription coverage has changed after only six months.
What is the drug formulary list? The formulary is a specific list of medications that a prescription plan covers at various prices, according to their own plan rules. Every prescription plan must offer at least two choices for therapeutic coverage of diseases and/or conditions.
Formularies have tiers that determine how much a patient will pay. Tier 1 is the lowest cost generics, Tier 2 may be higher cost generics, and sometimes preferred brand-name medications. Tier 3 may be non-covered generics, or non-preferred brands. Tiers 4, 5, and higher typically are for very expensive specialty medications.
Why do prescription insurance companies have formularies?
With so many medications available, it’s unrealistic to expect every one to be covered. Insurers negotiate tier placement, pricing and rebates with the drug companies annually. The pharmacy benefit managers (PBMs) like CVS CareMark, OptumRx, and Humana claim to reduce costs by managing drug tiers and prices, but there’s little transparency about how these savings impact consumers at the pharmacy counter.
How will I learn about a change to my prescription coverage?
By law, you should receive a 60-day notice in the mail that a medication will no longer be covered by the plan. A patient is allowed to have a 60-day “transition supply” to allow continuation of treatment in the short-term.
Pay special attention to these change notices, and tell your doctor’s office. Start the process to continue coverage, or ask to change your prescription to a more affordable product.
Why would an insurance carrier drop the coverage of a medication?
Sometimes reports of side effects are a cause for concern. For example, when long-acting single agent asthma inhalers had a strict labeling change, many PBMs switched their preferred formulary coverage for asthma inhalers to products with a better safety profile for patient protection.
What if I want to continue with the medication?
If your provider can provide documentation that the specific medication is “medically necessary,” the carrier may allow continuation on the same medication for the balance of the year.
Realistically, what are some steps I can take if my medication is no longer covered at an affordable price?
If obtaining a prior authorization or letter of medical necessity doesn’t work,
investigate the manufacturer website to learn about qualifications for patient assistance. Check savings cards like SingleCare/GoodRx/WellRx or others for a lower cash price with the coupon. Find out if CostPlusDrugs offers the medication at a favorable direct price.
Content provided is for educational purposes only, and is not intended as a substitute for advice from a qualified medical professional. The opinions expressed within are those of the author.
About the Author: Patricia Prewitt is a local Massachusetts resident who spent more than 30 years in the pharmaceutical industry. Tricia is a consumer education advocate, and loves helping people find ways to save money on their prescriptions. More information and free resources are available on her website at https://mypersonalrxadvisor.com/resources or call her at 508-507-8840. Favorite Quote: “Act as if what you do makes a difference. It does.” – William James
