ALEXANDRIA, Va., Dec. 6 /PRNewswire/ -- More
than 75% of Americans have a drug benefit, and with the coming
of Medicare drug coverage in 2006, millions more will, too.
The Academy of Managed Care Pharmacy offers the tips below to
help you learn pharmacy benefit lingo.
What's a drug formulary?
The list of drugs covered by your drug benefit
is called a formulary. It's usually reviewed and updated on
a regular basis by medical and pharmacy professionals. Ask your
plan for a printed copy of your formulary, or its internet address,
and make sure you supply that information to your doctor. If
your medication is not included in the formulary, discuss alternatives
with your doctor.
What's a copayment?
A copayment, or copay, is the portion of the
prescription drug cost for which you are responsible. The remaining
cost is covered (paid) by your plan.
What's a tier?
Drugs on a formulary are usually grouped into
tiers, often referred to as "generics," "preferred"
or "non-preferred." Your copayment will vary accordingly.
A copay on a generic may be $10, but a copay for a non-preferred
brand name drug may be half its actual cost.
What's a PBM?
A PBM is a pharmacy benefit manager, usually
a company that administers a drug plan on behalf of a sponsor,
such as your employer. PBMs work under a contract to provide
many services, evaluating drugs, monitoring care and keeping
expenses down to ensure your drug benefit is affordable.
What's a prior authorization (PA)?
Some drugs are dangerous for use by children,
older people or pregnant women. Others require careful monitoring,
are very expensive, or may have been prescribed for unapproved
uses. In any of these cases, your plan will require that you
obtain a PA in order for the drug to be covered.
What's an exception?
If the drug your doctor has prescribed for you
is not on your plan's formulary, you may ask for an exception.
If no similar drug or treatment is available, your plan may
decide to grant an exception and cover it.
What's an appeal?
If your request for an exception or a PA is
turned down, you have the right to appeal. Your plan will probably
confer with your benefit sponsor to determine whether or not
to cover the requested drug. But even if your plan doesn't cover
the cost, that doesn't mean you can't get the drug -- it only
means your plan won't pay for it.
If you knew the answers to these questions,
then you are well on your way to managing your pharmacy benefit
wisely. If not, clip this column and keep it for handy reference.
Provided by the Academy of Managed Care Pharmacy.
Our vision is improved quality of life through appropriate and
accessible medication therapy. AMCP has more than 4,800 members
nationally who provide comprehensive coverage and services to
the more than 200 million Americans served by managed care.
More news and information about AMCP can be obtained on their
website, at http://www.amcp.org.
