plans recognize how valuable the benefit isand are working very hard to maintain an NEW LAWS NEXT YEAR TO PROTECT
don’t examine whether the health plan pays to obtain medications and insurers trying to Published September 29, 1998,
keep a lid on costs has led to numerous con- Los Angeles Times
sumer complaints, and resulted in new laws Drugs: Prescriptions are the most-often
“because it’s the thing you use more often sumer-protection laws will go into effect.
seem to overlook them. Here’s how to get than any other benefit,” says Dee Konner, president and chief executive of Pharmaceu- disclose their prescription drug formularies.
tical Care Management Assn., an Arlington, The formulary is the catalog of products that health two years after having a liver trans- the plan will pay for. Another law ensures plant when he received a letter one day from that a patient can continue taking a particu- benefit, says Kassy Perry, executive director formulary or if the patient switches health sold to another company and that it would of Citizens for the Right to Know, a Sacra- mento-based consumer coalition represent- laries are necessary to control costs, ensure quality and track prescribing patterns.
Formularies influence doctors to use pru- cost with quality. They also help doctors than 40 years ago,” says Konner. “The idea was that there is no reason for a pharmacy to carry 50 different kinds of aspirin, for Until now, however, it has been difficult confirm that their health plan has one. A Citizens for the Right to Know survey of Cali- medications he needed daily to keep his new for osteoporosis, for example-carry steep health plans responded to a request to view price tags that can help drive up the cost to their formularies. (That number is up from The Santa Clarita man’s story bears some a similar survey in 1997, when 21% of com- important lessons for anyone picking a new panies responded positively to the request.) health plan. Don’t forget to check out the plan’s prescription drug benefit. And know rely on a specific medication. “This has what actions you can take to get the medica- drugs—up from $81.1 billion in calendar year been a huge issue for some people, such as the mental-health community,” Perry says.
“What really devastated me was that their Health, a health care information company.
approach was so nonchalant,” says Grass- works and legal affairs for PacifiCare, says years to switch patients with clinical depres- would cover the cost of medication ($1,300 health plans are anticipating a 15% increase for a 110-day supply). “They suggested I try another drug, usually Paxil. Perry says her another plan. They put it all on me. Cold.
“There has been a great deal of pressure Flat-out. One day you have it, one day you on the prescription drug benefit,” notes from PacifiCare members that they could no Susan Pisano, vice president of the American Assn. of Health Plans, a Washington, D.C.- Prozac and Paxil are both from a category focus on which doctor to select. You might based industry group. “The cost of the bene- of antidepressants called selective serotonin also check out which hospital you would be fit has been rising much faster than other sent to, should the need arise. But if you www.balf.org
“There will always be an incentive to dis- reuptake inhibitors and are chemically simi- pense the least expensive medication possi- lar but not identical, especially in the side ble.” But, Konner adds: “The industry can’t go too far afield and end up preventing peo- ple from getting what they need. They can’t “three-tiered” co-payment system that plans make it extremely difficult for people generic drug on the plan’s formulary for the “Most plans will say everything is cov- lowest co-pay, a brand-name medication on ered. But it’s the process that plans put in the formulary for a higher co-payment or a place,” Perry says. “How many hoops do you drug that is not on the formulary for the paid to grant favorable status to particular “If a patient wants to take a drug not on that you’ve failed on other medications the formulary, they can, but they have to pay before you’re authorized to receive another says Ron Yukelson, vice president for pub- more,” Konner says. “I think the consumer is lic relations at Health Net. “Yes, we will cost-conscious and they’ll go back and say, within certain classes of drugs. That’s not hassle. While the Prozac and the SSRI anti- to say that members won’t have access to depressant Zoloft are not on the plan’s for- medications their doctors say they need.” influence on a problem that is much harder mulary, he says physicians need only to call PacifiCare to explain the need to get a drug ple, details the HMO’s plan to use the drug We usually ask for the doctor’s reasoning maker’s Pravachol as its cholesterol-lower- doctors who keep tight reins on the costly in choosing Prozac over a drug on the for- prescriptions. Other plans monitor doctors mulary. The average wait time (to receive pril among ACE inhibitors that treat hyper- authorization) is five minutes,” he says.
Jones notes that in July, the last month for however, has no way of knowing if his or her the memo states are “superior” clinically, doctor is allowing such pressure to influence available, 4,500 prescriptions were written for Prozac and 2,300 for Zoloft while 7,500 all of them good products. But if a pedia- were written for the formulary choice: Paxil.
trician was told to prescribe Cefzil for a HMOs but is part of preferred provider orga- “If it was really difficult to get Prozac, we child’s ear infection, that might make some nizations, a looser type of managed care, wouldn’t have one third of our SSRI’s pre- uncomfortable, says Dr. Victoria Paterno, a said a health plan recently sent her a list of scriptions written for it,” he says.
patients for who she prescribed medications DEALS MADE WITH DRUG COMPANIES
cians’ Assn., a group that disagrees with “The letter said, ‘Do you know that there recommend?” Paterno says. “When you are advised to try the formulary drug first, Jones only has to be given twice a day. But the a part of these plans it can’t help but affect acknowledges. And the reason has to do pri- your thinking, even it it’s subconscious.” marily with cost. For example, since there are four SSRI antidepressants on the market, “I’m a pediatrician, and I know how it is from pressure to prescribe particular drugs, to try to force a medicine that tastes bad manufacturers to offer only their medica- down a kid’s throat,” Paterno says. “Then candid discussions with their primary care tions on the formulary in exchange for dis- there is the issue of ease of use. If you have counted prices. Under such an arrangement, “Consumers have to find out if their doc- tor is under financial pressure to prescribe manufacturer creates a new outlet for sales.
times a day, they would have to leave work one drug over another,” says Perry. “But the to give the child the medicine. The drugs I use may be more expensive, but if the child with $70 for Paxil, the formulary drug.
is more likely to get (all doses), it’s cheaper To examine your health plan’s prescrip- without laws to restrict them, health plans create their formularies based on financial A PUSH ON GENERIC MEDICATIONS
arrangements that do not, necessarily, have In this era of soaring health care prices, The Pacific Business Group on Health
the consumers best interests in mind.
control costs, says Konner. People should Citizens for the Right to Know:
PacifiCare medical group last year advised http//www.rtk.org
its doctors to prescribe to tricyclic antide- less, whenever possible and should not be pressant before trying an SSRI. Generally, tricyclics cause many more side effects and before demanding a higher-priced one.

Source: http://www.lfnc.org/OnlineLibraryHome/Health-Life%20Insurance%20for%20the%20Disabled/075e.pdf

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