Healthy Living for Life – Prescription Costs (Full Version)
28
December

By Paul Henry / in , , /


living longer living healthier living
better than ever before welcome to Mountain-Pacific’s Healthy
Living for Life a weekly series that gives you the information, education and
expert insight you need to become an active participant in today’s ever
changing health care climate here now as today’s program host Americans pay more
for prescription drugs than any other country in the world and according to
experts drug costs will only continue to rise in the coming years so what can you
do to reduce your prescription costs today we’ll talk about prescription drug
costs and how you can become an advocate for yourself when it comes to your
prescriptions welcome to Healthy Living for Life the show dedicated to helping
you do just that I’m your host Lisa Sather don’t go away
we’ll be right back welcome back joining us now is our first guest Mark Eichler
who is a Mountain-Pacific’s director of pharmacy services Mark has more than 30
years of pharmacy experience thanks for joining us today Mark thanks Lisa it’s
good to be here great so can you start out by telling us what a formulary is
and why health insurers have these sure a formulary is simply a listing of
medication that your insurer will cover for you they can be a listing of generic
medications brand name brand name medications or specialty medications
that you may be taking that you get from a specialty pharmacy it’ll also tell you
what your coverage restrictions are with that formulary it’ll tell you what your
coinsurance or co-pays for that formulary and it’s a way for insurers
and health plans to direct consumers to lowest net cost drugs that maintain the
same clinical and benefit as any one of the tiers and I guess we’ll probably
talk about the tiering you bet so interesting who chooses the drugs on
a formulary then is are these randomly chosen or there are some science behind
that yes there there is a science behind that most people don’t understand that
but there there is some significant amount of effort that goes behind
and choosing drugs on the formulary typically health insurers or health
plans will have engaged a pharmacy and therapeutics committee that P & T
committee will be comprised of pharmacists and physicians that help
evaluate new drugs as well as older drugs on safety and efficacy and then
place them in tiers along the formulary that and they’re also do an evaluation
of the cost structures of the medications too to again place those and
the tiers that we’ll probably talk about here shortly
absolutely so if someone has a copy of their formulary and they see that a
certain drug requires a prior authorization what does that mean a
prior authorization is simply a tool that health plans and insurers will use
and it’s mainly a process to limit or restrict certain medications for use and
we’ll probably talk about some other things in a little bit but prior
authorization can be done electronically it can be done by fax it can be done by
a telephone but it’s simply just a process that a health insurer will use
to cover medications appropriately for their members so why why I do health
insurers have these prior authorizations and what’s the whole point behind that
sure sure prior authorization is an important utilization management tool
used by health plans and insurers to ensure that medications are used
properly as well as certain medications have safety issues for example there
might be high chances for inappropriate use if not authorized in a specific
manner so that’s why health insurers and health plans have prior authorization
procedures so a term that our viewers may not be familiar with a step therapy
can you talk a little bit about what step therapy is surely the step therapy
is simply a part of that prior authorization process where where the
insurer or health plan will will require you as a user to step through certain
therapies before you can get to certain other higher cost therapies for example
because there’s a lot of medications on the market that don’t provide really any
more value than a generic medication for example so they might step you through a
generic tube before they allow you to have a brand name or places in therapy
for example some drugs are third line therapies so a health insurer may
require you to use a first line or a second line agent before you can use a
third line agent and that’s that’s what that step therapy is all about so can
that save our can that save folks money in fact step therapy can that actually
help save you know consumers dollars absolutely
for example if if the step therapy is requiring you to use a generic before a
brand that all will always save the consumer money because your copay for
the generic will be less it’ll also save your company if you’re if you’re
employed by a company that is a self-funded company for example and pays
their own bills of course the company won’t pay less and drug costs over that
there should not be any any decrease in efficacy or because of that step
therapies okay so let’s say somebody is in that step therapy process they’re
trying a medicine that they’re needing to you know utilize before they go on to
something else and they end up having a side effect or the medicine just doesn’t
seem to be working should what should they do
sure the the intent of step therapy is certainly not to impede or lock you into
particular drugs the intent is is is to save money for the plan as well as an
insurer but also be you know provide the same clinical benefit if you as a the
user of a step therapy program find that that drug that you happen to be step two
does not provide the clinical benefit that you and your physician wanted or
you’re having some adverse drug events from that or side effects from that
that’s when you inform your physician or your provider mid level or or other
about what you’re experiencing with that first-line therapy and then that you and
your provider then can make decisions about going from there
excellent so you mentioned tiers a little bit earlier and I wanted
to talk a little bit more about what why formularies have tiers and what is the
difference with each maybe you know in 30 seconds or so if you would be able to
kind of explain that sure drugs are covered on tiers and it’s made a way for
health insurers to have rank drugs by efficacy and safety as well as cost so
for example a tier one medication may be a generic medication with the lowest
cost share to you as the employee or the insured tier two medications might be a
brand medication to provide good value and good clinical efficacy tier three
medication might be one that is a non preferred brand for example there might
be generic options for that or there might be other brands that are cheaper
or actually provide better value to you as the consumer into the health plan
okay great stay tuned to learn more about
formularies and how you can be an active player in your health care especially
when it comes to your prescriptions we’ll be right back we’re back with Mark Eichler continuing
our discussion about prescription drug formularies now we’re going to talk
about common terms and formularies and prescription drugs overall first off
Mark though I just wanted to ask can formularies change yes Lisa formularies
can change but on a limited basis over the course of a plan year when for
example if a new drug comes out on the market or a new formulation of that drug
might or any drug might come out they have to be added to the formulary so
that can occur with throughout the year most drugs however that are established
on the formulary at the beginning of the plan year tend not to change formulary
status over that time period unless there’s maybe a new generic option for
example for a brand-name drug in the middle of the year the formulary may
change most plans offer at least a 60-day notice of any negative formulary
change and Medicare Part D plans are actually required to do that so if there
is a change in that formulary so if you’re on a particular medication and
the formulary tier status might change or it becomes non preferred for some
reason or has some step therapy or prior authorization procedures you’re required
to be notified within 60 days of that formulary change okay can you tell us a
little bit about quantity limits when folks see quantity limits on a formulary
what’s the purpose of that quantity limits are a way for your health plan or
your insurer to ensure appropriate use of certain medications some health plans
or insurers will only allow a 30-day supply of medications to be dispensed
some plans will allow you to get a 90-day supply of your medication in
either a mail facility or at a local pharmacy that’s up to the health plan
exceptions can always be made to that but there are also some particular drugs
that you know it’s not always good to have a 90-day supply of for example an
opioid or a narcotic medication dispensed to any patient so speaking
about a 90-day supply of medicines can you talk a little bit about whether or
not it would be more beneficial for folks to get 90-day
supply of verses a 30-day supply from a cost perspective that’s always a great
question and it’s one you should always have a good conversation with your
pharmacist about some plans allow like I just mentioned a 90-day supply either at
a retail store you can just walk in and pick up a 90-day supply some plans do
not allow that they there they want you to go to a mail facility so there are
ways that you as a consumer of that due save money typically your insurer or
health plan may only charge you two co-pays for a 90-day supply rather than
three co-pays if you got three individual 30-days supplies so there is
some some cost savings to you there’s also some cost savings to your planner
insurer as well or your employer something that comes to mind without is
weather so for example if somebody were to go ahead and use a mail-order
pharmacy can weather impact you know drugs if it’s too cold or too warm and
you’re getting something via the mail that’s a especially good question now
this time of year in the winter time we’re always worried or even the
summer time one that when the temperatures soar but typically
mail-order pharmacies that’s their business they know how to do that so I personally
don’t have a lot of concerns about medications being shipped through the
mail in times of temperature extremes for example there are some instances
however when if you’re going to be on vacation you might not be home etc so if
the delivery gets put in your mailbox at home and you don’t get to it for two or
three days that mailbox may be freezing or it may be real hot so you need to let
the people that are mailing that prescription to you know about that so
that you can be home when when you need to accept delivery to preferred pharmacy
is another term that comes to mind in terms of formularies what does that mean a
preferred pharmacy is simply a network that’s of pharmacies just like a network
of physicians or a network of hospitals that your health plan or or your insurer
has that the health planner insurer has
negotiated pricing for medications and then some plans actually close access to
preferred certain preferred pharmacies that simply it all it is it’s just a
network of pharmacies that your health planner insurer has chosen for you to be
have access to its pharmacist we often get asked you know our price is going to
be different from one pharmacy to another can you touch on that a little
bit that’s a great question it’s it’s kind of a loaded question the fact that
it’s a very the the drug distribution system and in in this country is is kind
of complex we have multiple ways for that drug from the manufacturer to get
to you as the consumer and so there are times when drug pricing is difficult you
might show up at one pharmacy for example if you are uninsured and we’re
paying cash the price that one pharmacy might be different than the price at
another pharmacy if you’re insured typically that co-pay or co-insurance that
you’re required to pay is generally the same no matter where you go but if
you’re uninsured and or using a cash price it’s important to always ask the
pharmacist about what that might be because in some cases even if you are
insured you can ask about a cash price that might be less than your actual
co-pay great so folks should ask questions to make sure that they’re on
the right track with really that’s the key yes all right well great thank you
we’re going to be continuing on here in a couple of minutes thank you for
sharing that up next we’re going to talk about some money-saving programs and how
talking with your prescriber and pharmacists could be good for your
wallet stay tuned welcome back to Healthy Living for Life
we’ve been discussing formularies and prescription drugs with Mark Eichler so
let’s talk about how a person can work with their doctor to find more
affordable prescription drugs Mark should a person bring a copy of their
formulary with them when they go to visit their doc Lisa that’s an
outstanding idea I wish more people would actually do that because that’s
physicians have treat patients maybe with 30 or 40 different
formularies in any given day so it’s really critical that if especially if
you’re a new patient or you’re expecting a new medication to be prescribed for
you bring a copy of your formulary even if you don’t understand that your
physician probably will and be able to help you with that excellent so
communicating with your doctor about alternative prescriptions could be
beneficial for you right absolutely so okay so what if your doc you go to your
doctor’s office and they don’t have time to review a formulary we know they’re
busy they’re seeing a lot of patients and that’s just that’s just the way it
is what what can you do as a patient well first of all as a patient I would
hope that would perhaps never happen that my physician I would hope that have
at least a few minutes to talk to me about my drug therapy because it’s such
a critical component of how my physician might treat me so but given that fact
you you might at least engage your physicians if you don’t have time today
I understand that is there a way that we can communicate via either email or can
I call you back some other time after hours whenever you know I understand you
might have a busy schedule today but I really need to engage you about my drug
therapy and and what might be best for me or give me a way to save money based
upon my formulary options being an engaged consumer that’s that’s important
so another question that comes to mind can your pharmacist help maybe choose an
alternative medication when you go to your pharmacy to fill your prescription
right at that point of fill is how does the pharmacist way into that are they
able to assist with that absolutely so and perhaps even more so than the
physician at times because they they fill prescriptions for all kinds of
people they fill prescriptions for various formularies every day so they
may be a little more in tune to that particular formulary they can inform you
about cash prices what your co-pays are going to be whether if you paid cash
outside of their prescription coverage whether you might save money
absolutely the pharmacist is who you really really need to engage in that
process they can help save you money as well as provide a very clinical in-depth
support for you they may even be able to communicate with your physician about
that too if yes yeah they can be your conduit to that physician
yes good so I know that some drug companies have drug coupons in fact I
just saw an ad last night on the television of course there’s always you
know get a hold of us for assistance some are given out by doctors offices
and available online so can you talk a little bit about if somebody starts with
a drug coupon and they use it for a few months and then they find out down the
line their prescriptions are going to be you know more expensive for example what
what’s going on what advice would you give folks you know that’s that’s a
really pertinent topic these days with the prices of medications being so high
either co-pays being high or if you were uninsured they’re just a sheer price of
the medication so manufacturer’s coupons are a way for manufacturers to discount
or provide you the medication either at no cost or low cost it’s a way for them
to get you on medication for example or if it’s a brand medication that might
not be covered by your formulary there’s ways to do that
coupons can be a little misleading or a little deceiving at times because they
might cover you or lower your co-pay or in some instance have no co-pay for a
limited period of time but after that time period is up you may be forced with
the full price of that medication that’s not now no longer covered by your
formulary so it’s really important to ask your pharmacist about how that
coupon works and what the ramifications are in the time limits
that might be associated with there really might be something less expensive
that is appropriate to use after that time absolutely I mean how many ads have
you seen on TV for new medications that you might become enamored with you want
to get that medication you ended up showing at the pharmacy with that coupon
for a free supply of drug well you didn’t know that that medication might
cost you two to three hundred dollars in the end so a lot of times brand-name
medicines have a generic available our generic medicines always less expensive
than the brand names in general they are but there are instances when the generic
medication may not be and there’s there’s some reasons for that
sometimes when a brand-name medication becomes generic manufacturers will have
an agreement with a generic company and they will they will authorize a generic
company to make the generic for but give them six months of exclusivity and in
that six month exclusivity period the difference in price between the brand of
the generic may only be 10 to 15% so especially on new entries into the
marketplace that may not occur as well as some formularies because of rebate
situations with the manufacturer to the health planner insurer may actually
prefer a brand over a generic so it may be cheaper for you as the consumer to
actually use the brand because your co-pay might be lower because the brand
is preferred over the generic okay can you talk about sticking with one
pharmacy is that a good idea to fill all of your prescriptions at one one
pharmacy absolutely in my opinion it’s it’s critical to use one pharmacy if you
can there’s all kinds of reasons why people choose their pharmacy cost
convenience but those are you know those are societal norms about we always want
to get things the cheapest we can and we always want to get them the quickest we
can but in some cases with your health and especially your prescription health
that’s not always the best idea a pharmacy has your complete
history and picture they know you they talk with you so it really is a good
idea whenever possible to use one pharmacy and choose that pharmacy wisely
excellent just in a few sentences can you hit on drug discount cards sure
what’s like the coupon a drug discount card is uses very similar mechanisms
sometimes if for the uninsured for example a drug discount card may offer
an opportunity to get a medication at a lower cost again it’s real critical to
have your pharmacy perhaps run that discount card against a prescription so
you know exactly what you’re going to pay before you actually pay for it
because if you leave the pharmacy and actually pay for it you can’t return
that making good excellent excellent information Mark thank you so much for
being here today I want to thank you for tuning in today as well I hope you found
our show helpful until next week stay fit stay well and stay healthy with
Healthy Living for Life Healthy Living for Life is brought to
you by Mountain-Pacific Quality Health we’d love to hear from you if you have
suggestions for future programs visit our website at mpqhf.org or call us at
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