Assisting #ACA Consumers with High Medical Needs

Consumers with significant medical needs especially want to make sure their providers are in-network, their prescription drugs are in a favorable prescription formulary tier, and the costs of routine doctor visits and prescriptions are affordable. Here are the steps I follow and some tips for working through each of these important plan selection considerations.

A printable version of this tip sheet can be found here.

1. Providers

The first step is to determine whether or not the consumer’s providers are in-network. While there are several ways to do this, I’ve found it is best to start with the insurance company. Here’s why:

Calling providers and asking whether they take Marketplace plans can be hit and miss, particularly if you live in a non-expansion state. In Texas, we’ve had provider offices just tell us, “We don’t take Obamacare,” when we call, as though Marketplace plans are some third category of coverage, as opposed to regular, private health insurance.

Even when provider offices want to help, this information is best verified through the insurance company. But this is also tricky because the Marketplace starts the plan selection process by comparing multiple plans, and it can be very time consuming to call every insurance company listed to check on one provider for each of their plans. To avoid this, I always start with the provider search for each plan/company as listed through the Marketplace. If those links don’t work, I do an internet search of the insurance company name and “provider search.”

The other reason to start with the company's online provider search feature is that it will give you a good sense of how the company refers to the insurance network that you’re trying to look into. The Marketplace has its own names for the plans and these are sometimes meaningless to a provider’s office. The network information on an insurance company’s website is likely the same information you will get if you called the insurance company.

Once the insurance options have been significantly narrowed down to the plans that have the relevant providers in-network, getting a second source of verification by calling the provider’s office is a thorough final step. Remember that a company may have different provider networks for each plan. So, be sure to ask the provider if they are “in-network” for the specific plan rather than asking if they take insurance from a particular insurance company (e.g., do ask, “Are you an in-network provider for Blue Cross PPO Platinum 50?”; do not ask, “Do you take Blue Cross?”).

2. Formularies
The second step is to narrow the plan choices to those that cover the consumer’s prescriptions. This step is a bit tougher since formularies include several tiers and different pricing for each tier.

Dosage can have an impact on a medication’s tier. Certain medications may also appear in various dosage forms, such as gels, capsules, tablets or injections, and formularies mayabbreviate each form differently. So it is never a good idea to check a formulary for medications based on a consumer rattling the medications names off the top of their head. Instead, ask consumers to bring a complete list of their medications that includes the dosage and dosage form. If a formulary lists the same medication name in different tiers, always ask the consumer what the medication is and in what form they take it to ensure you’ve located the correct medication.

Don't ignore any details in a formulary. All formularies should include each drug's tier and whether it requires prior authorization, step therapy, or has dispensing or quantity limits.

• Prior authorization (PA) means that the doctor must contact the health plan before prescribing the medication. Some insurance companies require that the consumer has already been taking this medication prior to when they sign up for the insurance plan.
• Step therapy (ST) essentially entails that a patient try less expensive medication options before they can move up a "step" to a more expensive option. It is possible to circumnavigate this process through doctor intervention. Make sure consumers know to check with their doctor to find out what steps are necessary.
• Dispensing limits (DL or  L) or quantity limits (QL) means the plan has set a limit on the quantity of a medication a patient can get over a certain period of time (e.g., 30 pills in 30 days). If more medication than the “limit” is necessary, the consumer will need her doctor’s assistance in providing the information necessary to get a refill.

If a medication has any of these three designations, make sure to go over how it will affect the consumer. Make clear to the consumer that all of these designations require action by their prescriber/doctor.

3. Prescription Drug Deductibles, Co-pays, and Co-Insurance
Third, always check to see if a plan has a separate drug deductible and whether each medication requires a co-pay or co-insurance. This information will help consumers with their financial and medical planning.

A drug deductible is a separate amount of money that a consumer must contribute towards medication costs before the insurance will cover medications. For medications covered with co-pays, the consumer typically pays the co-pay from the outset. But for medications covered with coinsurance, the drug deductible will affect the initial price the consumer will pay to get their medications. If a plan has a separate drug deductible, the drug deductible counts towards the overall plan deductible (i.e., the combined medical and drug deductible) and, of course, the plan’s out of pocket maximum.

If the medication's tier has a coinsurance, be sure to check the full price of the medication to calculate what the consumer will owe. A good website to use is GoodRX.com, which gives medication costs specific to local pharmacies. Make sure to check the price at a pharmacy that is in network with that plan.

4. High Cost Medications
Lastly, check to see if consumers can get a co-pay card for high cost medications. When I am working with a consumer and have noticed that a medication's tier and corresponding cost is high across many different insurance companies, I tend to search the medication online.

If the medication has only existed for a couple of years, it means the patent hasn’t expired, and legally, generic versions haven’t yet been created. That means that the medication is highly likely to have a co-pay card. The rule of thumb here tends to be that if a medication is relatively new and expensive, pharmaceutical companies create a way for consumers to get relief on their co-pay. The insurance company pays the bulk of the cost of the medication, so the pharmaceutical company "forgives" the far smaller portion of it they would regularly get from consumers. These can considerably defray what the patient pays for their medication.

If a co-pay card exists, you’ll find it by searching online. The consumer can sign up or you can sign them up. It usually takes only a couple minutes.

Make sure the consumer is clear that co-pay cards may function better with some plans than others. It will all depend on how the company tiers the medication and what the co-pay or co-insurance for that medications is. For example, the co-pay card may only work with co-pays and not co-insurance, and it may cover a set amount per month or a lump sum per year.

The co-pay card's function is particularly important when it comes to assisting patients who are HIV positive or have Hepatitis C because their medications retail for thousands of dollars per month.