Not only are health insurance plans likely to vary on their approach to costs, but they also use different procedures to determine whether they’ll cover your prescription drugs, a new study shows.
Some health plans employ internal teams to make these decisions, while others assign the task to outside consultants, according to the study, sponsored by the National Pharmaceutical Council and conducted by research firm RTI International. Health plans also differ in what type of information they use to make these decisions. For example, one plan might place more weight on peer-reviewed studies about a prescription drugto determine whether it'll be covered, while another might rely more heavily on the plan’s internal data, such as the treatment outcomes of other plan members.
Consumers should also take comfort in the fact that health plans look to an array of expert sources when it comes to evaluating drugs for specific conditions, says Susan Pisano, a spokeswoman for America’s Health Insurance Plans, a trade association for the health insurance industry. For example, a plan might tap the National Comprehensive Cancer Network Drugs & Biologics Compendium for guidance about a cancer drug, Pisano says.
A variety of approaches
The study examined 26 health plans. Most of them use medical directors and pharmacy directors as key members of the decision-making team, as well as specialists for certain conditions. “If a health plan were evaluating a new drug for rheumatoid arthritis, they would often bring in a rheumatologist to give expert input into how that drug compares to other drugs,” Halpern says.
All of the plans that participated in the study noted that a drug’s effectiveness was the most important factor in figuring out whether it would be covered.
However, that’s where the similarities end. Large health insurance companies typically spend more time and resources in the assessment process. They also are more likely to run the entire process internally, while smaller health plans are more likely to outsource the work to pharmacy benefits companies.
Cost also plays a role in the decision-making. Many plan providers place more expensive drugs on a higher tier, which means consumers will pay higher out-of-pocket expenses for them. However, some plans measure a drug’s effectiveness over time so that a drug that’s on a high tier may be re-evaluated and found to be more effective than alternatives. As a result, it may be put on a lower tier, making it less expensive for consumers.
A case for empowerment
While the health plans that participated in the study were not named, consumers can take steps to become aware of a plan's rules regarding drug coverage.
Consumers should look for transparency, says Jennifer Graff, the National Pharmaceutical Council's director of comparative effectiveness research. If a plan doesn’t post information about its decision-making process on its website, consumers can ask such questions as:
Consumers should look for transparency, says Jennifer Graff, the National Pharmaceutical Council's director of comparative effectiveness research. If a plan doesn’t post information about its decision-making process on its website, consumers can ask such questions as:
- What type of evidence is used to determine the effectiveness of a particular drug?
- Who makes the decisions about whether a particular drug is covered?
- How long after a drug is approved by the U.S. Food and Drug Administration is it reviewed by the health plan?
A good time to ask these questions is during open enrollment, when members can make changes to their health plans, particularly if an employer offers more than one health plan, Graff says.
Even if a drug isn't covered by an insurance plan or is considered too costly, consumers have options. They can look for assistance from co-pay assistance programs. For example, the Patient Advocate Foundation offers co-pay help to patients with chronic, life-threatening or crippling diseases.
Also, health plans typically offer generic drugs as an alternative to costlier brand-name drugs, Pisano says. In those cases, the generic drugs have undergone the same scrutiny as their more expensive counterparts, she says.
The bottom line: Consumers should take an active role in all facets of how their health care is managed.
By Tamara E. Holmes, InsWeb.com
