You Can Help Patients Navigate Changes to Prescription Coverage and Costs

By Lea Chatham  |  December 12, 2016

November and December are the time of year when healthcare is on everyone’s mind. Its open enrollment, and millions of people across the country are wading through their options and trying to choose the best plans for their families.

At the same time, the entire nation is watching to see what will happen when President-Elect Trump takes office. How will the changes he wants to make impact patients?

One of the many topics to tackle is rising drug costs. This is also a concern for patients as they review their potential coverage for the coming year.

CBS News reported for each person in the US, $858 was spent on prescription drugs in a year, compared with $400 across 19 other industrialized nations. The high price of medications is due, at least in part, to government regulations. Whether the new administration can curb these costs is yet to be seen.

Currently, what many are finding is a continued increase in premiums and high deductible plans (HDPs) and declining coverage for certain services and many prescription drugs. This is in addition the already high cost of medications.

This is because each year benefits change based on the usage of patients and cost of care. One of the areas most effected is medication coverage as leading insurance companies and the companies that manage pharmacy benefits, like Caremark, update their formularies.

According to GoodRx, this year’s excluded drugs are mostly those that now have a less expensive generic or similar alternatives that can be purchased at a lower cost. Caremark’s changes are mostly to drugs that have seen a significant increase in price recently, new biosimilar alternatives (these are generics for specialty and biologic drugs like insulin), and expensive cancer and hepatitis C medications. GoodRx has provided a list of excluded drugs for 2017 on its website.

Physicians are in a position to help patients. First, make sure you are talking to patients about their options, especially now as they are choosing plans. Encourage them to check the formularies if they are taking regular medications. People aren’t always aware of change in formulary coverage until their doctor or pharmacist tells them.

Second, consider offering a prescription discount program to patients. These programs are generally a card or voucher that allows the patient to access many drugs at a discounted rate. This way if they have a medication that must be paid for out of pocket they can get it filled at a reduced cost. You can provide cards at your office and some programs even integrate with your EHR to provide vouchers that can be printed when you are prescribing.

The challenge of paying for prescriptions medications not only impacts patients but practices as well. Provider reimbursement will be based more and more on outcomes. Helping patients access their medications and stay compliant can play a role in helping the practice meet requirements that will potentially increase revenue.

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