By Harry Thal
Special to the Sun
Insurance providers update their list of covered medications every year. This list is called a formulary, and it helps plan enrollees to understand whether or not their insurance will help pay for their medication.
More and more medications are removed from formulary lists each year. This means that if your medication was covered by your insurance last year, there’s a chance it won’t be covered this year. Formularies are important lists to pay attention to, as they can have a big impact on your healthcare spending and out-of-pocket costs.
Insurance companies work with pharmacy benefits managers (PBMs) to update their formularies. So, whether you have coverage through UnitedHealthcare (AARP), Anthem, Brand New Day, Aetna, Health Net Blue Shield or another insurer, your formulary is set by a PBM. To learn which PBM handles your pharmacy benefits, contact your member services at the phone number on the back of your insurance card; not your agent.
The two largest PBMs — managing pharmacy benefits for over 200 million Americans — are Express Scripts and Caremark. At the start of 2019, they removed over 90 medications from their formularies. Now, at the beginning of 2020, they are removing over 300 medications. That could mean that your medication will no longer be covered by your insurance.
The list of drugs generally includes brand-name drugs for which less expensive brand or generic alternatives are available. If your benefits are managed by Express Scripts or Caremark, you will likely have to pay the full retail price for drugs on this list at the pharmacy. You can find the estimated cash price for each drug by clicking on the drug names above.
If you notice that coverage is changing for a drug you take, talk to your doctor to see if a covered alternative might work for you. If you can’t switch, you may be able to use a GoodRx coupon to save up to 80 percent off the cash price. Go to www.goodrx.com for coupons. Unfortunately, the pharmacies in the Kern River Valley do not accept these coupons, so it might be worth a drive to Bakersfield. For qualified patients, manufacturer copay cards and patient assistance programs can also help to reduce the price of expensive medications. I refer to www.needymeds.com to learn about programs, sponsored by pharmaceutical companies, providing free and low cost medications to those who can’t afford the medication.
An important note about Medicare and private plans:
The new drug exclusions above DO NOT apply to Medicare plans; if your Medicare drug benefit is managed by Express Scripts, check your prescription coverage with your pharmacist or online through the Medicare.gov portal.
Also, some individual private insurance plans managed by Express Scripts or Caremark may have a different list of excluded drugs than the one above. This means that drugs on the list above may or may not be covered by your plan if you have coverage through work, for example. Please get in touch with your insurance provider if you have any questions about your coverage.
If you see a sharp rise in a prescription costs, feel you need to change your primary care physician, or you learn of better benefits on a different Medicare Advantage HMO plan, you may use this one time election and change Medicare HMO plans. This window is available for changes through March 31. Then the ability to change plans becomes more difficult or impossible.
On the subject of prescriptions, this week a gentleman came in complaining of the high cost of his insulin. I was able to reduce the cost to $0. By changing insurance plans, he also now has the same doctors, unlimited medical transportation as well as a Silver Sneakers gym membership.
Harry P. Thal, MA, is a licensed insurance broker in California (0621106) and 24 other states. His offices are in Kernville. He is a member of the Society of Certified Senior Advisors and Past-President of the Kern Association of Health Underwriters. He may be reached at 760-376-2100, e-mail firstname.lastname@example.org or visit him on the web at www.harrythal.com.