Non-Medicare plans typically are provided with several available options. What distinguishes most plans in this category are the patient populations they serve. Most plans are multitier with between three to five tiers per plan. These plans often promote the use of mail-order pharmacies. Mail-order pharmacies are offered to increase patient compliance and decrease costs. Most medications are filled for a 90-day supply when ordered through the mail. Most plans also direct patients to fill prescriptions through network pharmacies when not utilizing mail-order pharmacies. Plans require patients to pay higher costs when using out-of-network pharmacies.
Commercial employer plans differ in that fewer plan options are available. Typically, only one plan is available. Additionally, preferred drug lists are given instead of tiered drug lists. This results in fewer medications being covered by the plans. Prior authorization forms are not readily available, making it difficult to determine if additional coverage is possible. Also, several plans require login credentials, making it difficult for patients and providers to determine coverage. When plan information is available, it is listed on the employer’s benefits webpage. These plans are less likely to promote the use of mail-order pharmacies. Many plans link with large pharmacy benefits managers (ex. Caremark) to offer a predetermined drug list. Employers do not make it clear as to whether plan specific exceptions are made to drug lists supplied by the pharmacy benefits manager.
Medicare plans typically provide extensive information in regards to plan benefits. Prior authorization information and forms are readily available. In addition to tiered formularies, Medicare plans list which medications are included in Medicare Part B vs Part D. Additionally, Medicare formularies often have quantity limits listed within the formulary to limit the amount of drug that can be dispensed within a given time period. Formularies also have step therapy requirements in which some first-line therapies be attempted before articular medications are approved. Mail-order pharmacies are also available with many Medicare plans.
Studies have consistently shown that 20%–30% of medication prescriptions are never filled and that approximately 75% of medications for chronic diseases are not taken as prescribed. This resource center offers:
Understanding & assessing non-adherence to medications
Links to Script Your Future physician and consumer resources