Health plan tips for patients relying on specialty medications

Monday is the last day to begin the process of signing up for insurance under the Covered California statewide health exchange. But even for many of those already enrolled, the challenges are just beginning.

Consider, for instance, the work to be done in figuring out your new health plan’s coverage for prescription drugs. For people who take medications on an ongoing basis, it’s especially important to closely evaluate details of a health plan’s drug coverage.

For Tina Petrakis, selecting a new health plan through Covered California meant paying close attention to the medications each policy covered. Her 7-year-old son takes a cocktail of three prescriptions, which combined cost $1,200 a month without insurance.

“We don’t go to the doctor a lot, but we take medication,” says the 56-year-old science writer from the Bay Area city of Pacifica. “That’s where the majority of our healthcare costs are going.”

The plan she settled on stated in its summary of benefits that she’d pay no more than $50 for covered medications, a maximum price per prescription with which she could live, she says. But after her plan took effect, she learned that one of her son’s medications costing $194 a month wasn’t covered.

“I had to fork over the money myself to pay for it,” she says.

Experts say new plans sold on the health insurance exchanges include policies that can prove very costly — particularly for people in need of specialty medications used to treat rare and complex diseases.

For example, Bronze plans — the fourth-most generous available on Covered California — come with a $5,000 deductible. That’s how much you must spend out of your own pocket before getting any financial help from your insurer.

Lisa Nelson, senior director of state government affairs for the Leukemia & Lymphoma Society, says just one prescription for a cancer drug can come with a price tag of $8,000, which would cause people to hit their deductible in the first month. She says she worries that the initial financial burden will be too steep for most patients.

“We know patients will walk away from these prescriptions when the dollars get high,” she says.

In fact, a 2011 study published in the American Journal of Managed Care found that of patients required to spend more than $500 for frequently used oral cancer medication, 1 in 4 didn’t get their prescription filled.

In addition to high deductibles, experts worry about other costs associated with specialty drugs that would require patients with illnesses such as cancer, multiple sclerosis or rheumatoid arthritis to pay significantly more money out of their own pockets for medications.

If you rely on medications to manage a chronic or complex disease, experts offer these recommendations for effectively using your health plan:

Carefully check your plan’s list of covered drugs and what you’ll be charged. Petrakis says she checked the drugs covered by various plans before purchasing her policy, but missed the fact it didn’t cover one drug her son needs.

“When you sign up for these plans, there is really no easy way to check if your new insurance company covers your medications,” she said, “until it’s too late.”

The lists of drugs covered by health plans “are posted online but they’re not always complete,” says Karen Pollitz, senior fellow for health reform and private insurance with the Kaiser Family Foundation. Call the health plan directly to ask about the coverage for the medications you need.

Also check medical benefits. Many specialty drugs must be administered in a physician’s office. In that case, you won’t find them listed under your plan’s pharmacy benefit; they will be covered under the medical benefit, which comes with separate cost-sharing requirements.

The good news: These medications “tend to come at a lower cost that’s embedded in the physician visit,” says Jenna Stento, senior manager in the health reform practice at Avalere Health.

Follow your plan’s rules. Failure to follow your insurer’s guidelines can result in your claims being denied, even if the medications you need are covered by your plan.

For example, some medications come with the requirement that you first obtain your insurer’s pre-authorization before filling the prescription.

And, often, patients are required to try less expensive medications before gaining approval for pricier options.

If your doctor prescribes a name-brand drug for which a generic equivalent is available, expect your insurer to insist that you try the generic version before it will pay for the medication your doctor ordered.

Finally, Pollitz warns consumers to watch out for imposed quantity limits — another common insurance practice in which limited amounts of a drug will be dispensed at one time.

Consider buying a pricier plan. If you’re still in the market for a health plan and take a lot of medications, or require high-priced specialty drugs, you may save in the long run by buying a Gold or Platinum-level plan that comes with a costlier monthly premium but that covers more out-of-pocket costs when you go to fill prescriptions.

“We have found many cases of patients on specialty products who reach that out-of-pocket cap,” Stento says. “It can be worthwhile financially to buy up.”

Appeal to your insurer. If a drug you need isn’t covered by your plan, you have the right to appeal. The law entitles you to an internal appeal with your insurer and an external review by an independent third party.

When it comes to insurance appeals, Pollitz says, persistence is the key to success. “Never take no for an answer,” she says. External reviews rule in the patient’s favor about half the time, Pollitz says.

Petrakis appealed to her insurer and got a price break on her son’s medication. Her new co-pay is $70 a month, an amount still higher than what she anticipated when she signed up for the plan. Still, she says, “it’s better than $194, I guess.”

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Zamosky is the author of a new book titled “Healthcare, Insurance, and You: The Savvy Consumer’s Guide.”