-AP News, Feb 5, 2025
For those of us in healthcare, this story was particularly painful to read. This tragedy did NOT need to happen, and our hearts go out to the family of this young man who went without his asthma inhaler and passed away. We see firsthand how difficult this process has become for patients. This recent news story reflects what happens when the process is not clear, and communication with the patient has broken down. We offer condolences to this young man's family. Information is power - learn more about how it works so that you DO NOT go without necessary medication and risk health or even your life.
Why is it so complicated?
The system is very frustrating and complicated even for healthcare workers who deal with it daily. There have been many opinions on the "why" which we will not go into today, and leave those to our learned colleagues in healthycare policy, insruance commissioner's office and beyond. At Cara Direct Care, our patients are very familiar with this as we spend time trying to teach them how to advocate for themselves at the pharmacy and with their health insurance provider.
What can I do?
Read and save this post, which will hopefully help you to understand it more and help you to be part of the solution.
Why does my insurance not cover my medication?
Cara Direct Care patients are advised to utilize their health insurance pharmacy coverage where possible for prescription medication. Unfortunately, we often hear from patients that the prescription issued "is not covered by insurance" and is "no longer on formulary" . In previous years, the next step was that most pharmacies would call the physician and suggest alternatives. However this is no longer the case - we have stopped receiving these helpful calls from most pharmacies, most likely due to corporate policy changes on how pharmacy workflows happen. This means the patient is left feeling confused and calls us to try to help them figure it out.
Step 1: Medication not covered
You received notification from your pharmacy or insurance the your medication is no longer covered. We can help by looking at your insurance formulary and trying to figure out alternative medications that will work for your condition that ARE COVERED/PREFERRED medications. Let's start with a list of terms that we see in relation to your prescription coverage.
Prescription Coverage Terms & Definitions:
Formulary: A list of prescription medications covered by a health insurance plan. Formularies are typically divided into tiers, which determine the cost-sharing structure for each medication. These formularies are negotiated and updated annually and may change every year.
Tier: Categories within a formulary that group drugs based on factors like cost and clinical effectiveness. Common tiers include:
Tier 1: Generic drugs with the lowest co-payment.
Tier 2: Preferred brand-name drugs with a medium co-payment.
Tier 3: Non-preferred brand-name drugs with a higher co-payment.
Tier 4 (and higher): Specialty drugs with the highest co-payment.
Prior Authorization (PA): A requirement that a healthcare provider obtains approval from the insurance company before prescribing a specific medication to ensure coverage.
Generic Medication: A drug that has the same active ingredients as a brand-name medication and is considered bioequivalent in terms of dosage, safety, strength, route of administration, quality, and intended use, but is typically sold at a lower cost.
Brand-Name Medication: A drug marketed under a proprietary, trademark-protected name. These medications are typically more expensive than their generic counterparts.
Specialty Drugs: High-cost prescription medications used to treat complex, chronic conditions. These drugs often require special handling, administration, or monitoring.
Mail-Order Pharmacy: A service that delivers prescription medications directly to patients' homes, often providing cost savings and convenience, especially for maintenance medications.
Step 2: How To Check Your Insurance Formulary
Option 1: Search Online
Log in to Your Insurance Portal
Start by visiting your insurance company’s website. If you do not have a member account, create one. This step allows you to access information tailored to your specific coverage.
Find the Formulary
After logging in, look for sections labeled "Prescription Drug Coverage," "Formulary," or "Drug List." Many insurers feature a search tool for quickly locating specific medications. For example, if you're looking for Metformin, you can directly input its name for fast results.
Check Coverage
Search for your medication to see if it is covered. Pay attention to any restrictions, such as prior authorization or step therapy. These details can impact your ability to access certain medications. For instance, if your provider requires prior authorization for a medication, you may need to wait for approval before your prescription can be filled.
Option 2: Call Your Insurance Provider
Find the Customer Service Number
If you prefer speaking with someone, find the customer service number on your insurance card. This will put you in touch with a representative who can assist you.
Request Formulary Information
When connected to a customer service agent, ask about the list of covered drugs or information specific to your medication. You can also request a PDF copy of the formulary to be emailed or sent to you, which is particularly useful for record-keeping. For example, having a PDF can help you quickly reference prices or coverage options without logging in every time.
Step 3: Save a Copy of Your Formulary
Option 1: Download a PDF from the Insurance Portal
Locate the Formulary Document
Go back to your insurer’s website to find the formulary document. Once located, you can effortlessly download it to your device.
Download the PDF
Click the download button, often shown as an arrow pointing down. Choose a folder on your device where you can access the file easily. For example, you might create a folder labeled "Insurance Documents" for all related paperwork.
Option 2: Select and Save Relevant Pages
Open the Formulary PDF
After downloading the PDF, open it and look for the section listing your specific medications. This will give you vital information regarding coverage and restrictions.
Use the Search Function
Utilize the search feature (Ctrl+F on Windows or Command+F on Mac) to find your drug by name. This method helps extract only the necessary information. For example, searching for "Lisinopril" will quickly show you its coverage status without scrolling through pages of data.
Extract and Save Specific Pages as a New PDF
For Windows users: Open the PDF with a viewer like Adobe Acrobat. Click “Print,” select “Microsoft Print to PDF” or “Save as PDF,” and specify the pages you need. Name the file something recognizable, like "MyInsuranceFormulary2025.pdf."
For Mac users: Use Preview to open the PDF, then go to "File" > "Print" > "Save as PDF." Again, choose the relevant pages and give the new file a clear name.
Step 4: Send Your Formulary to Cara Direct Care
Upload a copy of your downloaded formulary to your patient portal or, even better, just the selected section for your health condition. We can look through this quickly and see which medications ARE covered, and what steps need to be taken to get the medication you need.
Step 5: Check for Formulary Updates in January
Remember to stay informed about any changes to your formulary, as these changes can significantly impact your healthcare costs. Regularly reviewing your coverage can lead to savings of 15% to 25% on some medications, depending on your plan.
Navigating your insurance formulary can seem daunting, but by following these simple steps to check your drug coverage and save your formulary, you can manage your prescriptions with confidence. Understanding your medications and coverage options helps you make informed choices that are vital for both your health and your wallet.
Finally, we at Cara Direct Care are always here to answer your questions and help you to maximise your benefits. Our patients have become very savvy at maximizing their healthcare savings, and we enjoy helping them save $$$!
Dr Clodagh Ryan
