Employer-sponsored plans footed most of the bill for the $154 billion in prescriptions filled last year. With drug costs expected to jump another 20% this year, companies are asking workers to pay a growing share. That $5 or $10 prescription co-payment will soon be history, and many companies plan to increase the amount to $20, $50, and more.
If you haven't seen those prices yet, you will. Corporations are working with pharmacy benefit managers (PBMs) that administer drug benefit plans to lower costs and shift more of the expense to employees. PBMs are steering workers away from expensive medications, using tiered systems to increase co-pays for some drugs, limiting coverage, and urging workers to fill prescriptions by mail.
Navigating tiered co-payments is one of the biggest challenges for plan participants. Generics have low co-payments; blockbusters such as Nexium, a heartburn medicine, and so-called lifestyle meds such as Viagra are at the top, where co-pays can be 10 times higher. A PBM's "preferred drugs"--the ones that cost less or give the PBM the highest profit margin--fall in between. Sorting through four or five pricing tiers to find the best drug for you will demand a high level of sophistication. "If you're not a doctor, you may have a problem," says Robert Field, health policy director at Philadelphia's University of the Sciences.
Managing your drug plan starts before heading to the doctor's. Get a list of drugs that your insurer covers--that's called a formulary. Most companies will supply one. But 14 states, including Pennsylvania, Delaware, and Minnesota, don't require disclosure of that information. If your company won't furnish a copy of its formulary, complain to your local lawmaker or state ombudsman.
When you get a list, take it with you on doctor's visits, where you can ask questions before the doctor writes the prescription. Is a COX-2 inhibitor such as Vioxx, which has a high co-pay, more effective than ibuprofen? Maybe not, but if you have gastric trouble, Vioxx might be better despite the cost. Don't pressure your doctor to prescribe the miracle pill you saw on TV. Heavily advertised drugs often land in the top tier of formularies, meaning they have the highest co-pays or they're not covered at all.
Since formulary lists change constantly as companies unload expensive drugs or add generics, ask for frequent updates. If a key medication falls off, you can appeal to your company to put it back on.
AdvancePCS (ADVP ), Merck-Medco, and other PBMs have a growing influence on what drugs you take. They manage drug benefits for 170 million people and process 70% of prescriptions filled in the U.S. They lobby physicians to prescribe certain drugs. Their computers alert pharmacists to ask doctors to rewrite prescriptions. And they offer savings and greater supplies to patients who fill scripts by mail through the PBM, which cuts out the pharmacist middleman.
Every plan has an appeals process for patients who need a drug that isn't covered. But all require heavy lobbying by your doctor, who will need to justify the prescription in writing. Whether your company grants an exception "will depend on how good a lawyer your doctor is," Field says.
Mail-order prescriptions can save money, but an order can take up to two weeks to fill. Finally, make sure you get what the doctor ordered--drug switching to generics or a lower-tiered drug happens more often with mail order than at drugstores. If you weren't told of a switch, reject it and complain to your company, doctor, and PBM.
If all this sounds like more work, get used to it. The days of casually strolling into the corner drugstore to pick up what your doctor ordered may be numbered.
By Lorraine Woellert