Many of us now have high deductible health insurance plans, which makes us “cash pay” patients until we meet our deductibles. The higher the deductible, the lower the monthly premium. If you have a high deductible and don’t consume much medical care, you are most likely a cash pay patient. You might even avoid medical care because of the out of pocket cost. I know I have.
As health insurance premiums increase each year, so do deductibles. Across the country, rates have increased 20 to 40 percent and up, making it difficult for many of us to afford anything but a high deductible plan. I talked with a friend yesterday who has a $9,000 deductible. She has a torn meniscus. She is avoiding the surgery because she isn’t even close to hitting her plan’s deductible. I suggested she try asking for a “cash pay” price from her surgeon and the hospital or surgery center where her procedure would be performed.
Negotiating cash pay prices for medical treatment has become a common practice. Even if you have health insurance you may want to pay cash. Often a cash pay price for medical care can be less than what you’d have to pay if your health insurance gets involved.
But be aware, cash pay discounts only work if your provider does not submit your bill to your health insurance company.
According to Gerald Kominski, director of the UCLA Center for Health Policy Research “If your insurance has a high deductible you should always ask for the cash price.”
After my family’s past health insurance company pulled out of the health insurance market at the end of 2015, we went with a Blue Shield plan. Our premium increased $125 a month and the plan covers less. Our deductible is higher. And they deny most medications.
This year, Blue Shield denied a medication I’ve been taking for years. Even after my doctor filed an appeal, they refused, suggesting I try similar medications that are obviously less expensive for them and not what my doctor prescribed.
I decided I was not going to let Blue Shield dictate my treatment if I could help it. I spoke to my pharmacist and asked what the cash pay price would be for the medication without submitting to our health insurance. The quote was too expensive to pay on a monthly basis. So I called a few pharmacies and asked for their cash price for my medication. I took the lowest price back to my pharmacy and asked if they would match it. They agreed.
You too can shop around for cash pay prices and not just for medications, but for other medical services. For example, if you need an MRI, call a few imaging centers and ask for their cash pay price. Be sure you make it clear you do not want it submitted to your health insurance. You can then negotiate with the provider of your choice.
- Offer to pay up front at the time of service in exchange for a discount cash pay price. Medical providers wait long periods to get paid by health insurance companies and some welcome being paid quickly.
- Offer to pay the equivalent in cash to the price your doctor or other healthcare provider might receive from your health insurance company. What many patients don’t know is that health insurance companies don’t pay what doctors or other providers bill. Health insurance companies negotiate a reduced fee so the provider is paid quite a bit less than what is initially invoiced. In anticipation of the reduced payment from health insurance companies, doctors and other medical providers increase the amount of the patient’s bill, according to Medical Billing Associates. Cash pay patients will be charged the same fee unless the patient negotiates a cash pay discount.
- Do not use a credit card as credit card companies tack on a fee, charging the end user a percentage of the bill. Offer to pay in cash, check or cashier’s check. My husband’s anesthesia bill from his surgery was paid by our past health insurance company with a credit card. The anesthesia group tacked on a $45 additional fee for credit card processing onto our bill. I put a stop to that. So can you.
- Go to Healthcare Blue Book, Clear Health Costs or New Choice Health and look up the desired medical service to get an idea of how much local doctors and hospitals charge for what you need. You might find that there are vastly different prices for procedures done in academic medical centers vs. surgery centers etc.
- Negotiate a cash price before you have a medical procedure. Be sure to get the name of the person you negotiated with at the medical provider’s office, and the exact price and date of the discussion.
- Ask about cash pay prices for other providers involved in your surgery or procedure. I’ve found that anesthesiologists are often not covered by health insurance. If you are negotiating a cash price don’t forget to ask to speak to the anesthesiologist too.
- You can negotiate a cash pay price after a procedure or treatment, but it’s easier ahead of time. If you receive medical bills from a hospital, per say, you can still ask for a discount. Try this: “I can pay 30% of the bill now if you will write off the rest.” If they do not agree, they might come back with an alternative reduction you find acceptable.
If you think that negotiating cash pay prices for medical care has an unseemly quality, you might consider how unseemly it is for health insurance companies to raise their rates at the current pace, how they increase the availability of high deductible plans while making lower deductible plans’ premiums unaffordable to most, all the while narrowing your choice of doctors and hospitals on available plans.
The drawback to “cash pay” for medical services, is that not submitting your claims doesn’t allow you to meet your deductible. If you anticipate a major medical expense, such as a major surgery or hospital stay, you might consider putting your medical services through your health insurance so your high deductible is met. That way the expense has a good chance of being covered. Minus the co-insurance, co-pay, and other deductibles, that is.
Resources for Discounted Medications
- Blink Health https://www.blinkhealth.com
- Good Rx http://www.goodrx.com
- NeedyMeds http://www.needymeds.org
Medical Billing/Dispute Advocates
Medical Billing Advocates of America http://billadvocates.com
Advocates for Arbitration, Lack of Access to Care, Medical Debt, and more.
Patient Advocate Foundation http://www.patientadvocate.org
For more information, please go to www.thetakechargepatient.com
Some say privacy is an illusion. I hope that isn’t true but I do know that our medical records are not safe. Why do I care? Because our medical records contain our social security numbers, health insurance information, our home addresses, phone numbers, emergency contacts and their phone numbers, our email addresses, possibly our driver’s license numbers, and likely credit card payment information if you’ve ever paid your co-pay with a credit card. I know I have.
Your medical record is worth 10 times more to a cyber criminal than your credit card number. And with healthcare’s mandatory transition to electronic medical records, cyber thieves have taken full advantage.
If you think major institutions are immune to cyber attacks, think again. You might recall the cyber attacks on our U.S. government. One in particular compromised personal information on 22.1 million people and 5.6 million fingerprints were stolen.
No doubt you’re aware of the major ransomware attacks on hospitals across the country where cyber criminals seized patients’ electronic medical records and held them for ransom to be paid in Bitcoin. See article here http://www.wired.com/2016/03/ransomware-why-hospitals-are-the-perfect-targets/
According to the Ponemon Institute’s Fifth Annual Study on Medical Identity Theft, 90 percent of healthcare organizations have been hacked, exposing millions of patients’ medical records.
You probably remember the major cyber attacks on the three major health insurers, Blue Cross Blue Shield where over 10 million patients’ medical records were exposed.
According to Modern Healthcare, nearly one in eight patients have had their medical records exposed in breaches in the United States. Since that article was published in 2014, that number has likely doubled.
You might be asking yourself, “What could cyber criminals do with my personal information housed in my medical records?”
Cyber criminals can monetize your personal information to obtain credit cards or loans, to commit tax fraud, send fake bills to insurance providers, acquire government benefits from Medicare and Medicaid, and much more. Your personal information can also be used to purchase healthcare services, prescription medications and medical equipment. It can also be used to obtain your credit report.
The above can also corrupt your medical history with inaccurate diagnoses and treatments.
According to the same Ponemon Institute study, 65 percent of medical theft costs each victim $13,500 to resolve the crime.
This is pretty scary stuff. I’ve heard from friends and colleagues that they can only take in small amounts of information because it’s so frightening and they feel it’s beyond their control.
There is something you can do.
It is up to doctors, hospitals, and other healthcare organizations/companies to secure their electronic medical records, back up hard drives, use secure cloud platforms (if there is such a thing,) encrypt emails, update software and more. Many just aren’t doing it.
According to the HIPPA Breach Notification Rule, a hospital or health insurance company that has been victim to a security breach, must inform patients, if more than 500 people have been affected. Unfortunately most do not. Patients find out about errors on their Explanation of Benefits (EOBs,) in letters from collection agencies, by finding mistakes in their health records or on their credit reports.
As a patient you are at risk. So am I. And we are all patients even if we just see a physician once every year or two. Had a baby? Had a vaccine? Been treated for the flu? All of us are patients and have been since we saw pediatricians as kids.
What You Can Do to Protect Yourself
- Read your Explanation of Benefits (EOBs) that come from your health insurance plan. Call your health insurance company if you do not recognize a charge. Check for total amount covered and amount paid.
- Get copies of your medical records from doctors and review them for errors. Look out for misdiagnoses, incorrect pre-existing conditions, procedures you didn’t have, incorrect treatments, allergies you weren’t treated for, and more. If you have trouble understanding your medical records, ask your doctor or his/her nurse to help you understand the information.
- Monitor your credit reports and billing statements for errors.
- Do not give out your social security number to anyone unless absolutely necessary. Often the last four digits will do.
- If you have your medical records or any personal information on your smart phone, be careful about using public Wi-Fi. If you send or receive an email or browse the internet while using public Wi-Fi, a hacker can eavesdrop on your transmission and gain access to the information on your device.
- Be wary of health apps. Generally, apps are not secure. See article here http://www.martineehrenclou.com/healthcare-data-mining-is-your-patient-privacy-being-breached/
- Be wary of public Wi-Fi. This includes any hospital. If you are a patient or visitor at a hospital, make sure the Wi-Fi is encrypted. If it is encrypted it will require a WPA or WPA2 password. Even if encrypted, think twice about sending any personal information via email or text while you are there.
- Set your laptop or computer to manually select the public Wi-Fi network in the healthcare facility you are in.
- Look for web addresses that begin with https. These are more secure.
- Do not share personal information on file sharing sites. Often they are not secure, according to Becker’s Hospital Review, 10 Ways Patient Data is Shared With Hackers.
1. Keep your firewall turned on.
2. Install and/or update your antivirus software.
3. Keep your operating system up to date.
4. Be careful what you download.
5. Turn off your computer at night.
For more information on cyber attacks, cyber security, data mining and patients medical records, see the following:
Rapid Increase of Cyber Attacks http://www.martineehrenclou.com/rapid-increase-of-cyber-attacks-on-patients-medical-records-8-tips-to-protect-your-data/
Patients’ Medical Records hacked at Alarming Rate http://www.martineehrenclou.com/patients-medical-records-hacked-at-alarming-rate-tips-to-protect-yourself/
Healthcare Data Mining: is your privacy being breached? http://www.martineehrenclou.com/healthcare-data-mining-is-your-patient-privacy-being-breached/
MedCity news reporter, Neil Versal’s article, Improv training helps Cleveland Clinic improve MD communication, describes Cleveland Clinic’s recent workshop to teach clinicians how to improve patient engagement!
It is super exciting to hear about because it means that powerful experiential teaching methods inherent in improv are reaching mainstream healthcare! Teaching methods that can help us with recalcitrant issues such as; patient safety, workforce health, and toxic cultures. And these claims are supported by research presented at the National Academies of Practice this past April by Candace Campbell, DNP, MSN-HCSM, RN, CNL, FNAP. Dr. Campbell’s poster presentation summarized her USFCA Doctoral Thesis entitled, “Improv to Improve Interprofessional Communication, Team Building, Patient Safety, and Patient Satisfaction”.
As a specialist in communication and collaboration, I’ve been integrating interactive improv activities into workshops with nurses for over a decade and in the last few years have decided more of an improv focus. Healthcare professionals already know what respectful listening and speaking up is supposed to look like, but we don’t the opportunities to practice building the skills and relationships we need. People are tired of taking typical communication courses and if we look at our patient safety data communication is a pervasive and chronic problem!
I had the pleasure of attending the first “Medical Improv” Train the Trainer at Northwestern University in 2012 led by professor and improvisor, Katie Watson, JD who has developed a curriculum for medical students.
I take improv for personal and professional development and have for over ten years. The activities are a lot of fun and I’ve grown a lot personally and professionally! We can take the emphasis off of comedy or performance and put it on the process, there is a rich gold mine of learning! In fact, you can’t participate in an improv activity without developing the emotional intelligence and interpersonal skills that we desperately need in healthcare!
It seems like a ‘no-brainer’ that all hospitals, clinics, and nursing homes should get some of this training, right? Ah yes, but we need more research, more trainers, more money, which could take years, right?
We can create a train-the-trainer resource this year through the crowdsource funding project, “Improvoscopy: Serious Play for Safe Care”. Please take a few minutes to explore the idea and consider a contribution. We don’t need to wait!
Beth Boynton, RN, MS, author of Successful Nurse Communication: Safe Care, Healthy Workplaces, & Rewarding Careers, is a speaker and medical improv trainer. More information about her work can be found on at www.confidentvoices.com and she can be contacted at email@example.com.
By Beth Boynton, RN, MS
As a consultant and author specializing in teaching emotional intelligence (EQ) and communication skills to healthcare professionals for over a decade, I can attest to the critical need for and barriers we face in developing them. Further, it is important for all stakeholders to understand these challenges so that we can work together effectively for positive change. In this post I want to discuss these issues, share an exciting crowdsource project, and ask for your help. (If you already believe that promoting EQ will help us solve problems in safety, patient experience, and workforce harm, skip down to the section on “Good News”!)
EQ is all about self and others. It includes the ability to show empathy, honor other points of view, and empower others, and acknowledge accountability. In a service industry so focused on human beings it seems obvious that nurses, physicians, and other healthcare professionals should be proficient in this skillset. Yet many are not and given the ‘high-stakes’ work of healthcare, ensuring the workforce has related training is a call-to-action for all of us.
How Does Emotional Intelligence Manifest in the Workplace?
Whether highly developed or lacking, EQ is an underlying theme in human interactions. For instance, as an RN, I need to show empathy for patients and be able to listen to their concerns not only to make clinical assessments, but to understand their needs and worries. I must also be self-aware of my own limitations associated with fatigue, overwhelm, and/or tragedy. I need to trust that I will be respected and heard if I report a problem and able to set limits, ask for help, and delegate tasks respectfully while in an environment where my limits are respected, help is available, and there are staff to delegate to. I need to be respectful of others’ limitations and be in tune with their social cues. Also, my ability to give and receive constructive feedback is fundamental to ongoing quality improvement which is a cornerstone to a culture of safety.
While physicians and other healthcare professionals have different roles and perspectives, this complex realm of EQ poses similar needs and challenges. For example, a physician must be able to show confidence, authority, and directive leadership while always being open and respectfully responsive to input from others.
What Happens When Emotional Intelligence is Lacking?
In a general sense, individuals who lack EQ are not able to take good care of themselves and/or work effectively and respectfully with others. This results in poor communication, teamwork, and leadership which in turn contribute to mistakes, poor patient experience, and/or harm to the workforce. Here is a some relevant data to drive this point home.
- An estimated 1100 preventable deaths every day associated with hospitalizations in the USA.
- Communication, Human Factors, and Leadership are leading root causes of catestrophic errors year, after year, after year! (See page 8 of this Joint Commission report on root causes of sentinel events, ).
Patient Experience Surveys
- The Hospital Consumer Assessment of Healthcare Providers and Systems’ (HCAHPS) surveys that measure patient experience are rich with feedback about interactive behaviors of staff. Of the 32 items surveyed, 14 are directly related to communication and emotional intelligence such as, “During this hospital stay:
…did nurses treat you with courtesy and respect?
…did doctors listen carefully to you?
…did nurses explain things in a way you could understand?”
“Through the Eyes of the Workforce” is a 2013 report from the National Patient Safety Institute that details physical and psychological harm experienced by the healthcare workforce. Some statistics taken from the report include:
- Health care workforce injuries 30 times higher than other industries
- 76% of nurses in national survey indicated that unsafe working conditions interfere with the delivery of quality care
- An RN or MD has a 5-6 times higher chance of being assaulted than a cab driver in an urban area
- Lack of respect is a root cause, if not THE root cause, of dysfunctional cultures 95% of nurses report it; 100% of medical students; huge issue for patients.
These important issues are often treated as separate phenomenon yet when we consider EQ, a common and underlying problem emerges: we are not doing a very good job working together and the results are very serious!
Challenges to Developing Emotional Intelligence
As essential as it is to promote EQ, there several challenges we face in training healthcare professionals.
First, is a persistent lack of time. Medical and nursing educational programs are so packed with scientific and clinical studies that there is little time for learning EQ beyond cursory efforts. The lack of time for developing EQ persists once students graduate and begin practice. High-stakes, high-stress clinical issues are always the priority. Time for managing conflict, offering constructive feedback, or coping with tragedy, is chronically unavailable. Some of us may even use this perpetual state of reaction to avoid doing deeper work!
Compounding this lack of time is the need for psychological safety in order to develop and practice the skills. The same environment noted above is not at all conducive to taking emotional risks that can be involved in speaking up and listening. Since speaking up requires the risk of being more accountable and listening requires a sharing of power, either can be very difficult for someone who does not have a confident sense of self. The psychological risks of trying out new behaviors are made even more difficult by blaming or bullying cultures.
Another challenge we face is that the kind of expertise necessary to build EQ is very different from memorizing scientific facts or researching data. Teaching EQ requires skills in facilitation, coaching, conflict management, and the ability to create a safe learning environment. A skill-set not common in clinical leaders.
And so we have a lack of skills, a lack of expertise to teach them, and workplace environments that are too risky to practice them. A perfect storm for the longstanding issues we’re facing.
There is Some Good News
A new kind of experiential teaching called Medical Improv is a growing field of interest. A speicific form of applied improvisation and in my experience, one of the most effective ways to teach EQ, communication, teamwork, and leadership. If we can help nurse, physician, and administrative leaders learn how to teach some of the fundamental improvisational activities we could create a far-reaching rippling effect.
And that is exactly what Improvoscopy: Serious Play for Safe Care is designed to do. This project will involve filming improv workshops and then editing video bites that emphasize teaching strategies and learning opportunities. These will be used to build an online library of videos and lesson plans that will empower them to train others. Activities for building EQ can then be integrated into staff meetings, orientation, strategic planning, and clinical inservices. Voila, powerful experiential learning without a huge time or financial commitment! Please consider checking out Improvoscopy project, sharing the idea, and contributing at any level! Thank you very much and if you have questions, please let me know!
Beth Boynton, RN, MS, author of Successful Nurse Communication: Safe Care, Healthy Workplaces, & Rewarding Careers, is a speaker and medical improv trainer. More information about her work can be found on at www.confidentvoices.com and she can be contacted at firstname.lastname@example.org.
There’s a new Barbie in town. There’s nothing appealing about Hello Barbie, developed by Mattel. In fact it’s downright Orwellian. Well-meaning parents, grandparents and other loved ones might not know what they are getting into when they give Hello Barbie to a 6 to 8 year-old-child.
Hello Barbie has a microphone and speaker that allows it to capture and engage in conversations with your child. This is no wind up doll from decades past that spewed pre-recorded greetings.
All your child has to do is press a button on the Hello Barbie’s belt buckle and talk into the speaker. A recording of your child’s conversation is then transmitted through your Wi-Fi connection to a company called ToyTalk. Speech Recognition Software converts the audio recording of your child into text. Artificial intelligence software allows Hello Barbie to respond to your child based on keywords extracted from your child’s words.
Hello Barbie is like a baby monitor that talks back. Remember the hackers who hacked into baby monitors and scared the living daylights out of the children and the parents? See article here. Each one was accomplished by hacking each family’s Wi-Fi.
Hello Barbie collects every detail of what your child says to it and saves it on a cloud based storage platform. The information is used to create personalized conversations with your child. See Newsweek article, Hello Barbie, Your Child’s Riskiest Christmas Present.
Not concerned yet? Read on.
Mattel and ToyTalk capture popular topics your child talks about to Hello Barbie. For example, your daughter or son confesses to the doll that she/he wants to see the new Disney movie coming soon to theaters. Hello Barbie may have thoughts about upcoming local showings of that Disney movie.
Getting the picture?
Does this remind you of how social media sites and Google insert ads according to your online searches and preferences on the internet?
It gets worse.
Parents have to download a mobile app and connect to Hello Barbie through their wireless network (Wi-Fi.) In essence, parents grant their permission for their child’s data to be stored, translated into text and shared with third party companies.
That is if parents read the fine print.
Another disturbing angle is that parents have full access to all of their child’s audio conversations with Hello Barbie. But to gain access to their child’s recorded inner secrets, they must allow ToyTalk to hold on to the information.
To say that this is an invasion of the child’s personal privacy is an understatement. It’s worse than reading a diary.
Even more disturbing, is that parents can also share their child’s personal conversations with Hello Barbie on Facebook and Twitter with a simple push of a button. This just isn’t right. Posting a child’s personal conversations on Facebook or Twitter is a violation of a child’s privacy. What 6 or 8 year old can grant permission to a parent to post his/her conversations with Hello Barbie on social media and understand the repercussions? Some parents might not think that their children have rights but I do.
There’s something else even more sinister that you have to consider regarding Hello Barbie. Given the number of cyber attacks on large banks, Sony, the U.S. government, health insurance companies, hospitals and more, what is to stop hackers from retrieving information from your Wi-Fi network through which your child’s conversations are transmitted? What stops a hacker from hacking into the server on which your child’s data is stored?
Imagine a 6 year-old child’s conversations with Hello Barbie. Most likely, information would be shared about where he/she lives, who he/she lives with, the school the child attends, names of friends, and more. Would you want your child’s personal conversations stored on ToyTalk’s servers? No server is immune to hacking no matter what companies claim.
This reminds me of the new “Smart TVs.” Samsung makes one that actually eavesdrops on the owner’s conversations. If you have a “Smart TV” that is connected to the internet, you can flip a switch to turn on the voice recognition feature that allows the TV to follow your voice commands, instead of using the remote control. That feature allows the “Smart TV” to listen to everything you say even if you don’t want it to. Your words are then processed by the television and then transmitted to a third party. Even Samsung warns, “Please be aware that if your spoken words include personal or other sensitive information, that information will be among data captured and transmitted to a third party through your use of Voice Recognition.” See link here.
Like Samsung, Hello Barbie also uses Voice Recognition software. Why wouldn’t the same warning apply to the doll?
Child privacy advocates don’t like Hello Barbie either. The Campaign for a Commercial-Free Childhood has launched a campaign it calls #HellNoBarbie that warns parents about the toy. They are concerned that a child’s conversations are going straight to the advertisers. They might be right.
Personally, I would not buy a Hello Barbie for any child. Not just because I think it’s creepy, but data can be extracted from any number of servers through the storage and sharing of that information and used for a number of nefarious purposes.
FAMILY FINANCE HEALTHCARE
13 Smart Ways to Save on Prescription Drugs
Kara Brandeisky @karabrandeisky Feb. 29, 2016
Save 40% or more on the medications you need.
Your medicine may come with a new side effect: financial pain. Prescription-drug spending grew 12.2% in 2014—five times as fast as the year before—according to the Centers for Medicare & Medicaid Services. And the sickest Americans bear the biggest burden. Some 43% of those in fair or poor health say it’s somewhat or very difficult to afford their medications, and 37% say they’ve skipped out on filling a prescription because of cost, according to the Kaiser Family Foundation (KFF).
What has changed? Generic drugs, long an affordable alternative to name-brand medicines, have become part of the problem. The average price of the 50 most popular generic drugs increased 373% between 2010 and 2014, according to OptumRx, a pharmacy benefit management company. One culprit is consolidation: After a decade of mergers, three big companies now control 40% of the generics market, says Gerard Anderson, professor at the Johns Hopkins Bloomberg School of Public Health. Weaker competition means drug companies can charge your insurer more. Meanwhile, pricey new miracle drugs—like hepatitis C treatment Sovaldi ($1,000 per pill for an 84-pill course)—are also a key factor forcing up overall medication costs.
In response, insurers are making consumers pay more, and work harder, to get their prescriptions—if the drugs are even covered. “We’re seeing plans limit the choices of drugs that are available,” says Sandy Ageloff, senior consultant with Willis Towers Watson.
Fortunately, there are plenty of ways for you to save. By making strategic changes in the medications you take (with your doctor’s okay, of course), the places you buy them, and the insurance plan you elect, you may be able to shave 40% or more off your total prescription-drug costs this year. Here are the steps you need to take.
CHANGE YOUR MEDICATION
1. Substitute generics for name brands.
First things first: If you haven’t already, ask your doctor if you can try any generic versions of your prescription meds. Despite recent price increases, the savings can still be immense. On average, Americans on employer plans could have shelled out as much as 80% less in co-pays in 2015 by switching from a branded drug to a generic, according to KFF data. “The evidence is very strong that generics work just as well,” says American College of Physicians president Wayne J. Riley.
2. Combine pills—or split them.
If you are taking several medications for the same condition, ask your physician if there’s a single pill that would do the job. For example, your insurer could make you pay a combined $100 or more a month to get a brand-name beta-blocker and a brand-name thiazide diuretic to treat high blood pressure, Riley says. But most people, he says, can sub in a generic combination pill containing both medications, which will probably have a co-pay of less than $15.
Alternatively, you might be able to save money by splitting some pills, Riley says. You’ll need to check with your physician, because not all doses can be divided safely—but once you’ve gotten the green light, ask for a prescription for half as many double-strength pills. Then buy a pill splitter and cut the tablets in two.
3. Check the formulary for your insurer’s favorites.
The list of medications that any given drug plan will cover—called a formulary—has gotten much more complicated. As little as 15 years ago, most plans had no more than two tiers, or price categories. The two-tier plans would charge you one co-pay for generics and a second, higher one for brand-name drugs. By 2015, however, 81% of workers had three or more tiers in their prescription-drug benefits plan, and 23% had four or more, according to KFF. Obamacare and Medicare plans have multiple tiers too.
Generally, the higher the tier, the more you pay. While first-tier (usually generic) drug co-pays were just $11 on average in 2015, fourth-tier co-pays averaged $93 per prescription.
And co-insurance—in which you pay a fixed percentage of the price, rather than a set dollar amount—could push your out-of-pocket costs even higher. Among plans with three or more tiers, 40% required that patients pay co-insurance on pricier fourth-tier drugs, putting an average 32% of the cost on your shoulders.
“It can make for some confusion at the pharmacy counter,” says Sharon Frazee, vice president of research and education at the Pharmacy Benefit Management Institute (PBMI). “If you don’t know where the drug sits on the formulary, you don’t know how much you’re going to be charged.”
Plans use tiers to lower costs. Your insurer will save money if you switch to a cheaper, clinically equivalent drug. The plan may also have negotiated better prices with one manufacturer by promising to charge more for the competition.
Either way, many plans offer incentives to switch. Show your doctor your formulary list and ask if there’s another drug in a lower price tier that would work just as well for you.
4. Jump through your insurer’s hoops.
In 2015, almost 70% of employers required, for at least some drugs, that you try over-the-counter, generic, or lower-cost versions before insurance would cover the pricier alternatives, according to a survey from PBMI. More than half of all employers required such “step therapy” for cholesterol-lowering drugs, for instance, up from 38% in 2010. This process can make it tricky for patients to get the expensive drugs their doctors have prescribed.
“A lot of health insurance companies are requiring that patients try three medications before they can get the one that their doctor originally recommended,” says health care consultant Martine Ehrenclou.
If your drug has such restrictions, you’ll get the bad news when you go to the pharmacy to fill your prescription. Work with your doctor to try the alternatives; if you ignore the rules altogether, you could get stuck with the full bill for your medication.
What if you have already tried the treatments your insurer is pushing? “You don’t have to start over,” says Katy Votava, founder of health insurance consulting firm Goodcare. Go to the drug section of your insurer’s website. You can send your doctor’s staff the necessary authorization forms or, in some cases, initiate the process yourself, says Votava. Your insurer should spell out the kind of documentation you’ll need.
5. Ask your plan to make an exception.
Your plan might waive restrictions, pay for a drug that’s not on its list, or charge a lower co-pay if your doctor says a specific medication is necessary.
For example, when cholesterol-lowering drug Lipitor went generic, many plans refused to cover the brand-name version or charged a higher co-pay, says Tatiana Fassieux, board chair of California Health Advocates, a Medicare advocacy nonprofit. But some people couldn’t take the generic because they were allergic to the binding additive, so plans let them take branded Lipitor or pay the generic co-pay for the branded drug.
Ask explicitly for an exception: You again go to the drug section of your insurer’s website, but this time look for a medication exception request. Give it to your doctor’s office to complete, says Riley of the American College of Physicians.
Request denied? You have the right to both internal and external reviews. Your plan’s explanation of benefits document will tell you whom to contact.
For all Medicare Part D plans, call your provider and ask to have the exception form sent to your doctor, Fassieux says. If your request is rejected, you can appeal.
CHANGE YOUR PHARMACY
6. Use mail-order options.
If you don’t use mail order for common maintenance medications, you’re probably overpaying. More than 90% of employers offered the service in 2015, and almost a quarter of those required it for at least some drugs, PBMI says. Processing can take a week or more, so when you’re starting a new medication, ask your doctor for one 30-day prescription to fill locally plus a 90-day script for mail order, Riley says. On average, you’ll save a third on co-pays for brand-name drugs when you buy through the mail.
7. Use a preferred drugstore.
Almost three in 10 employers had a preferred network in 2015, meaning workers got a discount at certain drugstores, according to PBMI. Another 13% had a limited network, meaning insurance paid only for prescriptions filled at in-network chains. Medicare plans can also have preferred or limited networks. Preferred pharmacies generally offer good discounts, Frazee says: “The savings can be considerable, particularly if you’re on brand medications.”
Free to choose any pharmacy? Use the OneRx app to see which ones offer the lowest prices. Take a photo of your insurance card, and the app will show estimated co-pays based on your plan. The app also shows cash prices, the amount you would pay without insurance; these can sometimes be less than your co-pay, says A.J. Loiacono, chief innovation officer at Truveris, which created the app. Just remember that if you bypass your insurance, the payments won’t count toward your deductible or out-of-pocket maximum.
8. Beware of online pharmacy scams.
When looking at online drugstores, be cautious. Many of the “Canadian pharmacies” you’ll find on the Internet are fraudulent, according to a 2013 Government Accountability Office report—which also noted that some drugs ordered online contained “dangerous contaminants, such as toxic yellow highway paint, heavy metals, and rat poison.”
You can be sure a web pharmacy is safe if its domain name ends with “.pharmacy,” which means the site has been approved by the National Association of Boards of Pharmacy and meets all regulatory requirements. You can also search for the site’s name on LegitScript.com to confirm that it’s aboveboard.
CHANGE YOUR INSURANCE
9. Check your insurer’s formulary lists.
To make the biggest dent in high drug costs, you may need to change your insurance. Employers usually let workers choose new health plans in the fall; Obamacare marketplaces are on a similar timetable. And seniors can choose new Medicare plans starting Oct. 15.
To compare plans, start by checking the formulary lists to ensure that medications you take are covered, Votava says. (These lists are often online, but in some cases you may need to request the document from a prospective insurer.) Identify which tiers your drugs are in, and then use each plan’s “summary of benefits and coverage” to see how much you would pay in each tier. “Get used to doing a little more homework,” Votava says.
Drug coverage is of particular concern for people on Obamacare plans, some of which have placed all the necessary drugs—even generics—for certain chronic conditions in the most expensive tier. A 2014 study by the Pharmaceutical Research and Manufacturers of America identified higher drug costs for Obamacare enrollees with cancer, diabetes, rheumatoid arthritis, and even asthma. And a New England Journal of Medicine study found that HIV patients on plans with such “adverse tiering” owed $3,000 more than HIV patients on other plans, even after accounting for out-of-pocket maximums and premiums.
Trying to calculate what you’d owe? Get help. “Call the pharmacy help desk for your plan,” Votava says. “They are going to be your best shot.” Tell the rep the plan you’re considering and the medication you’re on, she says, and ask what price you would pay.
10. Check for tricky deductibles.
For many patients, drug co-pays kick in from the first day of coverage. But last year, KFF found, almost a quarter of workers on high-deductible employer plans had to pay full price for prescription drugs until they met their overall deductible—more than $1,300 for individuals and over $2,600 for families. That could require a big outlay for people with high drug costs.
And 36% of employer plans in 2015 had a separate drug deductible, up sharply from 14% in 2014, according to PBMI. On average, drug deductibles are $325 for individuals and $960 for families. “You go to the drugstore more than you go to the doctor, so you’re more likely to feel it faster,” PBMI’s Frazee says.
At least one change has delivered a measure of relief. Under the Affordable Care Act, all new employer and marketplace plans must cap how much you’d pay for in-network care each year. In 2015 the average out-of-pocket max was $3,291 on individual PPO (preferred provider organization) plans, according to KFF. So if you face high drug costs, you may be able to save by choosing a plan with higher premiums but a lower cap. To gauge your potential liability, add a given plan’s premiums to the out-of-pocket max, Votava says.
11. Price out Medicare options.
Part D beneficiaries have a somewhat different set of rules and concerns. Unlike employer and marketplace plans, Medicare drug plans have no out-of-pocket maximums, so you can continue to hemorrhage cash if you’re taking expensive drugs.
Meanwhile, out-of-pocket costs can vary widely between plans, notes a KFF survey. For example, a drug called Spiriva, used to treat emphysema, costs a Medicare Part D beneficiary as much as $472 per month in 2016 on one plan—but as little as $33 on another. Diabetes treatment Lantus Solostar ranges from $29 to $172 a month; generic cholesterol drug atorvastatin costs $20 a month on one plan but is free on another.
You need to shop around every year; Fassieux says coverage lists change all the time. The Medicare Plan Finder at Medicare.gov makes it easy to search plans, however. Enter your medication information, including dosage and frequency. You can also enter the name of your favorite pharmacy in case some of the plans have preferred or limited pharmacy networks. The tool will show you your expected costs on both Medicare Part D and Medicare Advantage prescription-drug plans.
Again, remember that what was cheapest last year won’t necessarily be the right answer this year, even if your drug regimen hasn’t changed.
“We see people who didn’t look at their plans; they didn’t do anything,” Fassieux says. “Then they go to the pharmacy, and their co-pay has tripled.” Don’t be among them.
AND IF ALL ELSE FAILS…
If you take a high-price brand-name drug and have exhausted other ways to reduce your costs, you may need extra help. Two options:
12. Clip coupons.
Some drugmakers offer discounts directly to patients. If you take any brand medications, says health care consultant Martine Ehrenclou, check the manufacturer’s website for coupons. (Medicare beneficiaries are ineligible.)
13. Ask for help.
Pharmaceutical companies also have patient-assistance programs to aid people who have a hard time affording their treatment. There may be income limits and other requirements. Check RxAssist.org, patientadvocate.org, and pparx.org to find programs for your medications.