Tips for Making Insurance Open Enrollment DecisionsWritten by Expert Pharmacist
August 25, 2022
Contributor: Dr. Staci-Marie Norman, PharmD, DCES
Welcome to fall! School has started, and I’m betting there are Halloween displays in stores near you! As we head towards the end of the year, many of us face “open enrollment” for our insurance, whether through our employer, open market, or Medicare. This can be an extremely confusing decision, especially if you are taking costly medications - and there are many in the world of diabetes care! When looking at your choices, ensure you have an accurate list of your current medications. If you and your physician have discussed the possibility of adding a prescription, make sure you have that medication name or at least it's drug class. You will be looking for and comparing a few things when choosing your insurance plan:
- Is the medication I am currently taking covered? This is the most important question and the first thing to consider.
- If my medication is not covered, is there an alternative in the same drug class that is covered? For example, you currently take Lantus (glargine), which is not covered, but Basaglar (glargine) is covered. Both are glargine, but you will need a new prescription from your doctor for the change because they are not generically substitutable. Or 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.
- What will my copay be? Policies are set up in a few different ways regarding copays (the amount you pay at the pharmacy). Two of the most common copayment options are percent of total cost and tiered based on generic vs. brand, total cost, and formulary.
- The percent of total cost seems straightforward - you pay more as the cost of the medication goes up. But you might have a smaller percentage owed on generic versus brand name medication. So, your generic glimepiride may only cost you 10% of the total, whereas your brand name Janumet costs 20%.
- With tiered copays, generally, generic medications are in the lowest tier. Expensive generic medications and brand-name medications are in the next tier. The third tier is typically the most expensive medications and may even need approval for use (called prior authorization or PA). Alternatively, you may have to show that less expensive therapies have failed before you can use third tier medications.
- 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 3 is $40. Or the tiers may be set up as different percent amounts, such as tier 1 is 5%, tier 2 is 20%, and tier 3 is 50%. In the percent model, you have a more significant cost burden as the costs of your medications rise.
- What is my deductible, and how does that relate to my copay at the pharmacy? A deductible is an amount you must pay before your insurance pays. You may be used to seeing this at the beginning of the year, but some newer policy options can make trips to the pharmacy a little frightening.
- High deductible health savings accounts (HSA) are great as a built-in saving account for health care needs that will continue to roll over for future needs.
- The downside is that the deductible you will have to attain is typically around $5000 per year. But you can use your HSA account to pay for those deductibles.
- One thing to look at with this type of plan is if “preventive” healthcare and medications are covered outside your deductible. For example, you have a $0 copay at an annual physical exam, but if you had to see the doctor for an infection, your plan would put that fee towards your deductible, and you would be responsible for payment. This can also work at the pharmacy. An example is a medication like a statin, used to lower cholesterol and decrease your risk of heart disease, has a $0 copay. But a hormone replacement medication would go towards your deductible because it is used to provide symptom relief but not for preventing health complications.
Considering all these aspects should help you make a more informed decision on the plan you choose for the upcoming year.
In addition, there are a few things that can help lower your final cost at the pharmacy counter:
- There are manufacturer coupons for brand-name medications if you have regular commercial insurance (not government-sponsored like Medicare or Medicaid). Many of these coupons will lower, if not eliminate, copays. But there are catches:
- Always read the fine print. It may say $0 copay, but there might be a statement of the maximum payment amount in the fine print. For example, you have a manufacturer card that says $0 copay but will only pay up to $100 per prescription. If you have a high deductible account and the medication costs $150, the whole $150 will show up as going towards your deductible to your insurance, the manufacturer coupon will pay the maximum of $100, and you will pay the remaining $50. Even though it isn’t the $0 copay you might have been expecting, it still is a win because you only had to pay a third of the bill while getting credit for the whole in the eyes of your insurance. So that high deductible may not end up being as high!
- There could be a “lifetime max” on the card. If the card is good for a lifetime max of twelve prescription fills, you will be back to your full copay amount on fill thirteen.
- Make sure you are approved for the medication. If your medication is FDA approved for 18 years of age and up, and you are 17 years old, the copay card will not work.
- Many copay cards do not work if you are uninsured. However, there could be other resources that the drug manufacturer may provide to you if you inquire.
- Government-sponsored insurance plans are not eligible. If you are insured through Medicare, Medicaid, or the VA, using these cards and your insurance is unlawful.
- Any time you are prescribed a name-brand medication, look for a copay card. Ask your doctor about a copay card or go online to the manufacturer's site to look for one. You must be on the manufacturer's site because many discount cards out there will say they can lower your cost by 70%, which may be true on some generics. But on brand-name medications, they may not reduce the price very much.
- Another cost-saver is a discount card such as Good Rx and SingleCare. These discount cards promise cost savings of up to 70% and can be extremely helpful with generic medications, especially if you have a high deductible plan. For example, if you have a $5000 deductible that needs to be met, and you are taking metformin and glipizide (both generic medications), you would likely pay less using the discount card rather than your insurance. The only downside is that if you use the discount card, your payment doesn't go towards your deductible. But in the metformin and glipizide example, a whole year's worth would not come close to meeting the deductible, so why not save money? The discount card would not be helpful on more expensive brand-name medications. They might reduce the cost by five or ten dollars, but none of that would go towards your deductible. And as mentioned, this is where the manufacturer coupon is your best bet for lowering your out-of-pocket cost.
I hope this will help you navigate the “open enrollment” season and help you avoid being 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.