Navigating Insurance Open Enrollment

A Healthier You

Navigating Insurance Open Enrollment

Staci NormanContributor: Dr. Staci-Marie Norman, PharmD, DCES

Welcome to fall! I really cannot believe the leaves are starting to change and there are Halloween and even Christmas displays in the stores! Where has this year gone?

As we come to the end of the year, many of us face “open enrollment” for our insurance, whether through our employer, open market, or Medicare. Insurance options can be extremely confusing, especially if you take expensive medications for chronic illnesses such as diabetes.

When you start to look at your choices, make sure you have an accurate list of your current medications. If you and your physician have been discussing the possibility of adding on a medication, make sure you have that medication name or know the drug class in which it belongs.

There are a few things to looking for and compare:

  • Coverage: Is the medication I am currently taking covered? If not, is there an alternate medication in the same drug class that is covered? For example, if you currently take Lantus (glargine) and it is not covered, but Basaglar (glargine) is covered. Both are glargine, but you will need a new prescription from your doctor for the change. Or if you currently take Jardiance, but the plan will cover Farxiga. Both are in the SGLT2 family, but again your doctor will have to change your prescription.
  • Copay - Percent of Total Plan: Percent of total cost seems straight forward - you pay more as the medication cost goes up. But you might have a smaller percent owed on generic versus brand named medication. Your generic glimepiride may only cost you 10% of the total, but your brand name Janumet is be 20% of the total cost.
  • Copay - Tiered Plan: With tiered copays, generally generic medications are in the lowest tier. Expensive generic and brand name medications are in the next tier. Finally, the highest tier is typically medications that are the most expensive. You may need prior authorization or proof that less expensive therapies didn't work before these medications are covered. The cost of these tiers is typically a "straight" copay amount. An example would be tier one generic is $0, tier two is $10, and tier three is $40. Or copays could be set up as different percentages, such as tier one is 5%, tier two is 20%, and tier three is 50%.
  • Deductibles: A deductible is the amount you must pay before your insurance begins coverage. You may be used to seeing that at the first of the year, but some policy options can make our trip to the pharmacy a little frightening.
    • High deductible health savings accounts (HSA) are great in that there is a built-in saving account for health care needs, and it will continue to roll over for future needs. The downside is that the deductible is typically around $5000 per year. Your HSA account can be used to pay for those deductibles.
    • Remember to check if "preventive" healthcare and medications are covered outside of your deductible. For example, you could have a $0 copay at an annual physical exam, but if you had to see the doctor for an infection, you would be responsible for payment, and the cost would be put towards your deductible. At the pharmacy, a medication like a statin (used to lower cholesterol and decrease your risk of heart disease) may have a $0 copay. But you may have to pay the full cost of a hormone replacement medication, which will go towards your deductible because it is used to provide symptom relief but does not prevent health complications.

There is one more thing that you can do to help lower your final cost at the pharmacy counter. There aremanufacturer coupons for brand-name medications if you have regular commercial insurance (not government-sponsored like Medicare or Medicaid). Many of these coupons lower, if not eliminate, your copay. But there are catches:

  • Always read the fine print!! It may say $0 copay, but there may be a statement of maximum payment amount. For example, you have a manufacturer card that says $0 copay, but it will only pay up to $100 per prescription. If you have a high deductible account and the medication costs $150, the whole $150 will go towards your insurance deductible. The manufacturer coupon will pay the maximum $100, and you will pay the remaining $50. Even though it isn't a $0 copay, it still is a win because you only had to pay a third of the bill but got credit for the full amount in the eyes of your insurance. So that high deductible may not end up being as high!
  • There may be a "lifetime max" on the card. So, if the card is valid for a lifetime max of twelve prescription fills, you will be back to your full copay amount on your thirteenth refill.
  • If you are insured through Medicare, Medicaid, or the VA, unfortunately, it is unlawful to use copay cards along with those types of insurance.
  • Ff you are uninsured, you may find that many copay cards require insurance coverage. However, there may be other resources that drug manufacturer can provide to you if you inquire.

I hope this information helps you navigate through the open enrollment season and that you won't be shocked at the pharmacy counter in January.

Dr. Staci-Marie Norman, PharmD, DCES received her bachelors from Purdue University (’94) and her Doctor of Pharmacy from the University of Oklahoma (’96). In 2000 Dr. Norman added to her credentials by becoming a Certified Diabetes Care and Education Specialist. She is currently the Clinical Coordinator and staff pharmacist for Martin’s Pharmacy. Dr. Norman is a national faculty member for the American Pharmacist Association, teaching certificate programs in both diabetes and cardiovascular disease. She serves on the advisory board that oversees development and revision of these programs. Along with teaching and development responsibilities for APhA, Dr. Norman serves as a peer reviewer for research grants and publication submission. Dr. Norman has also spoken for Abbott, Bayer, Lilly, Mannkind, and Lifescan as a diabetes specialist.