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Understanding Prescription Benefits

July/August 2001

For people living with HIV/AIDS, prescription drug benefits are an important part of care necessary for success of any treatment regimen. Drugs must be affordable, accessible, and available without interruption. As a community pharmacist, I get lots of questions about insurance coverage. Believe me when I say it is confusing to providers as well as the patients! Let's try to sort out some of the facts.

Because the insurance industry, Medicaid, Medicare, AIDS Drug Assistance Programs (ADAP) and Social Security are all regulated by state or federal government agencies, there are variations on benefits and restrictions from one state to another. For example, an ADAP program in State A may only pay for antiretrovirals, while State B also allows drugs for opportunistic infections, lipodystrophy, and lipid control.

Prescription drug benefits given by employers are the most complicated. In general, the pharmacy portion of health insurance provided by employers is a small part of an entire package of benefits. For the majority of the public who may only need a couple of prescriptions filled a year, medications are not a big priority. Those living with HIV/AIDS need at least five or six prescriptions every month. You are usually locked into a program for a year, or until there is an "open enrollment" opportunity to change policies. It is important to understand your plan so there are no surprises at the pharmacy.

Co-pay is the amount that the patient must pay for each prescription. It is usually a fixed dollar amount. Sometimes there are two co-pays: a higher one for brand name drugs, and a lower price for generic drugs. Co-pays must be paid at the time the prescriptions are picked up. These co-pay fees are slowly getting higher and higher. It is not unusual to see a $30 co-pay on each prescription. With many prescriptions a month, it really adds up. Some policies have percentage co-pays rather than a fixed amount, usually 10% or 20%.

Formulary plans only allow you to get certain drugs using your insurance; other drugs would have to be purchased at the full price. At this time, I know of no formulary plan that excludes any antiretroviral, but I have seen these plans exclude drugs for other conditions such as opportunistic infections and depression. A list of drugs covered by insurance is provided when you enroll. Ask your doctor to look over the drug list. Keep a copy of it in your medical records and give one to the physician so that it can be used when prescribing new drugs. This will save you (and me) a lot of time and aggravation at the pharmacy. Providers writing prescriptions for those with HIV/AIDS have to be concerned about drug interaction with the antiretrovirals, especially the protease inhibitors. The "recommended" drug that is offered on the formulary may not be the correct choice for you, requiring you to pay the full retail price for the best choice.

Mail order options are offered to patients receiving "maintenance drugs" or drugs that are needed for long periods of time, as opposed to prescriptions that are needed and used immediately. This can save money because of lower co-pay amounts. The drawback is that you have to be organized to plan ahead to place orders and have refills placed by the physician. This option does not allow for face-to-face consultations with the pharmacist, but a pharmacist can be contacted through a toll free telephone number.

Most prescriptions are filled for 30 days, with a couple of days leeway. Some insurance companies are very strict about allowing early refills, as when planning a vacation. Mail order prescription plans allow for 90 days of supply to be dispensed for fixed co-pays.

When drugs are "not covered" by an insurance company, a prior authorization can be obtained to by-pass this ruling. This usually requires the physician to write a letter or submit a form to the insurance company to explain the need for the drug. It usually takes a few days to even weeks to get this accomplished.

Some policies specifically exclude injectable drugs. Testosterone, human growth hormone, and maybe the new fusion inhibitors could possibly be excluded under this restriction.

Under limited access, you may be required to use only certain pharmacies to obtain refills.

Discount plans are not a good option for HIV-positive patients. Instead of paying the full retail for a three-drug regimen of about $1,000, the discount may only be 10%, leaving $900 still due from you.

Reimbursement plans could be a problem as well. Even though the insurance company may pay 80% for example, it requires the patient to pay the total pharmacy bill up front and wait for the insurance company to send a check. Some pharmacies may agree to take an assignment of benefits. The pharmacy will charge the patient the deductible (20% in this example) and then will wait for the check to be sent directly to the pharmacy from the insurance company. Pharmacies can charge vastly different prices under this plan, so do your shopping!

Glen Pietrandoni is director of Clinical Pharmacy Services for the Walgreen Specialty Pharmacy, focusing on HIV, located in the Howard Brown Health Center of Chicago.

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This article was provided by Positively Aware. It is a part of the publication Positively Aware. Visit Positively Aware's website to find out more about the publication.
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