Has your small group health insurance company recently denied your prescription? Are you having prescription drug challenges? Or does your prescription cost a lot more using your new insurance?
Prescription drugs continue to exceed the cost of traditional medical care. Because of this, Nevada health insurance companies are paying close attention to the amount that they pay for their prescription drug benefits. I think that we are all aware of the increased prescription costs. The prices increase at the drug counter because of changes to our health insurance plans each year. Although, we are able to avoid this by knowing how our insurance covers prescription drugs.
Insurance companies can change the pharmacy co-pays (over the counter costs) on their health insurance plans. They also have the ability to change both their Pharmacy Benefit Managers (PBM’s) as well as their Formularies. This helps reduce their pharmacy expenses.
Pharmacy Benefit Managers are separate companies that contract with health insurance companies.
Locally, both Prominence and Hometown Health Plan contract with MedImpact. This is because they are a separate Pharmacy Benefit Management company. These separate companies process and pay their prescription drug claims. Larger health insurance companies like Cigna, use integrated pharmacy systems. They administrate their own pharmacy programs inside their own organization. Both Pharmacy Benefit Managers and integrated pharmacy systems are responsible for processing and paying prescription drug claims. They also maintain the formulary, contract with pharmacies, and negotiate discounts with drug manufacturers.
A Formulary is a list of prescriptions that are approved, by the Pharmacy Benefit Manager. The different categories include Generic, Preferred brand-name, Non-Preferred brand name, and Injectable. Unfortunately, a new category of “Not Covered” has been generously added to the previous four. The Pharmacy Benefit Manager can also limit the dosage of specific prescriptions. They can also require step-therapy if a patient wants coverage for higher-priced pharmaceuticals.
A list of our local company Pharmacy Benefit Managers are listed (here):
Prominence – MedImpact
Hometown Health Plan – MedImpact (Recently added SaveMart)
Anthem – Express Scripts ( Largest in the US )
Cigna – Cigna Pharmacy Management (internal)
United Health Insurance – Optum Rx (combined with Catamaran)
If your plan isn’t covering your prescription drugs and for more information about health plan compliance with the Affordable Care Act, please don’t hesitate to call any one of our five Washoe County Resident health insurance brokers. Our services are always free of charge and we look forward to helping you meet the Affordable Care Act requirements.