Consumers Face Obstacles in Understanding Prescription Coverage

Consumers Face Obstacles in Understanding Prescription CoverageIN CALIFORNIA
Consumers Face Obstacles in Understanding Prescription Coverage
Consumers find it frustrating and time consuming to get information about their prescription drug benefits, according to a report by the California HealthCare Foundation (CHFC). CHFC surveyed consumers as well as agents and enrollment counselors. Publicly posted formularies are hard to navigate. They often feature arcane terminology, provide incomplete and inaccurate information, and are not available in languages other than English.

Many consumers don’t think of checking whether their medications are covered before selecting a health plan. But those who seek this information have a hard time finding it. Participants say that prescription benefit information is not prominent on plan websites or on the Covered California website. Many participants say that it took multiple clicks to locate a company’s formulary, if they were able to find it. Most were unable to find all the information they wanted, and resorted to calling each plan under consideration to check whether their drugs were covered and get details on their financial responsibility.

In general, consumers are not familiar with many of the terms used routinely in prescription benefit information, such as “formulary,” “prescription drug tier,” “co-insurance,” and “preferred drug” versus “non-preferred” drug. Consumers want materials that are written in more common, accessible language. The following are more key findings:

  • Consumers have little awareness of how to request medications that are not on a plan’s formulary.
  • When shopping for health insurance, drug benefits take a backseat. Consumers base their health plan choices on monthly premiums, physician access, and out-of-pocket costs, such as deductibles and copays for physician office visits.
  • Consumers have often assumed that their drugs would be covered so they didn’t double-check their availability or potential cost.
  • Neither agents nor counselors routinely help clients conduct drug benefit searches. Agents in the study say that it is too time-consuming to be profitable while counselors say they have limited familiarity with the process.
  • Study participants reviewed online formulary search tools. The Colorado Health Plan Finder tool is well-received among consumers and agents because it offers filters to refine plan options. Shoppers can view only plans that cover their drugs. It also displays the copays. Participants said that it allowed them to figure out what they would be spending monthly on prescriptions.
  • Information throughout the Covered California website was consolidated into a table to clarify relationships among prescription coverage and metal tier options. Agents say that having the information presented this way is useful when explaining drug costs to clients. Consumers are split on whether they could understand all elements of the table.

Respondents offered the following suggestions:

  •  Have an online tool with drug cost and coverage information, by plan. An interactive Internet formulary search tool would allow consumers to input drug names. Results would include details, such as cost and tier placement for each plan.
  •  Health plan websites should consolidate drug benefit information under a clearly labeled tab that’s easy to find with a minimum number of clicks.
  • A formulary should specify whether it is for individual or group plans or those included or excluded from Covered California.
  • Consumer education should address the differences among formulary designs. There should be particular attention to educating consumers on how to appeal medication denials and seek redress of other prescription drug coverage issues. Enrollment counselors want additional education on prescription benefits.
  • Use the term “prescription drug list” instead of “formulary.”
  • Drug categories should include understandable terms like “high blood pressure” instead of “hypertension.” Other suggestions are to standardize formulary terms and abbreviations to make comparisons less confusing.
  • Display copay information with tier placement, the cost of monthly prescriptions, the difference between branded drugs and generics, information on step therapy, the appeals process, and a list of pharmacies.

To get the full report, visit

Health Net Reaches Out to Those Affected By the Wildfires
Health Net will approve payment for any essential prescription medications (at the usual copayments and deductibles) for any Health Net member in California, Oregon, and Washington whose medicine was lost in a wildfire or remained behind during an evacuation. To get an emergency supply, members need to return to the pharmacy that filled the original prescription. For questions, affected Health Net members can call 800-400-8987.

Health Net members who lost their homes or have been evacuated due the wildfires can contact MHN, Health Net’s behavioral health subsidiary, for referrals to mental health counselors, local resources, or phone consultations to help them cope with stress, grief, loss or other trauma resulting from the fires. For the duration of the fires and their immediate aftermath, affected Health Net members can contact MHN 24 hours a day, seven days a week at 800-227-1060.

Health care providers who contract with Health Net can call 800-641-7761 for guidance on prescription refill guidelines, authorizations for treatment, or approval for out-of-network services in the event a contracting provider or facility becomes unavailable. Depending on how the fire situation plays out, Health Net says that it can make additional changes to its policies, as needed, to help ensure that members have access to necessary health care services.

Fresh Data on ACA Show the Effects of Health Reform
The uninsured rate reached a new low in the first full year of the ACA health insurance marketplace operation. A smaller share of Californians delayed or skipped necessary medical care, according to a survey by the California HealthCare Foundation (CHFC). The survey also found the following:

  • The number of uninsured Californians under 65 dropped 12%, falling from 16% of the population in 2013 to 14% in 2014, a new low.
  • Notable decreases in uninsured rates were found among people living below 138% of the federal poverty level and among African Americans.
  • The share of the population age 18 to 64 enrolled in Medi-Cal rose by 52%.
  • The share of uninsured Californians reporting cost as the reason for lacking coverage dropped from 53% to 43%, although lack of affordability remains the most common reason cited for going without insurance.
  • Most non-elderly adults who went without necessary care said it was because they couldn’t get an appointment.
  • In certain regions, such as Northern/Sierra counties, more people had a hard time finding primary care physicians and specialists who accept new patients or their insurance than in 2013.

For more information, visit

CDI Makes It Easier for Providers to Submit CE Courses
Continuing education (CE) providers can now submit course applications, course renewals, and course completions online to the California Department of Insurance (CDI). Vertafore’s Compliance Express service offers a faster online option for submitting courses and course renewals to the CDI. The cost is $10 per course application and $5 per course renewal. For course completions, the cost is 50 cents per student for every credit hour completed. When using Compliance Express services, CE providers will be billed monthly. In addition to the service fees, costs include CDI’s course application fee ($34) and course renewal fee ($13) fees.

CE providers can also input and modify course schedules and look up information about their provider status, course status, and transaction history free of charge. Visit to set up a free subscription. For account and service questions contact Sam Meyer at For billing and technical questions, contact Sircon Support at 517-381-3860.

CMS Steps Up Support for Agents during Open Enrollment
The National Association of Health Underwriters (NAHU) applauds the Centers for Medicare and Medicaid Services (CMS) on committing to providing more dedicated customer support for agents and brokers to help individuals, families, and small businesses sign up for health insurance in the federally facilitated marketplaces. Janet Trautwein, CEO of NAHU said, “This increase in support, through the existing call center, will enable agents and brokers to provide the best service possible to consumers seeking health insurance. NAHU is pleased our discussions with CMS have resulted in positive steps toward making healthcare more efficient and accessible.”

NAHU Supports Small-Group Market Legislation
The National Association of Health Underwriters (NAHU) is urging Congress to support the Protecting Affordable Coverage for Employees Act (H.R. 1624), which would give states more flexibility in determining their small group market instead of relying on a single national standard.

Beginning January 1, 2016, the definition of small employers will change from groups of up to 50 employees to groups of up to 100. This change is mandated as part of the Affordable Care Act (ACA). Janet Trautwein, CEO of NAHU said, “This small-group expansion will prevent mid-size employers from keeping the plans they have; they will have to select a new plan offered in the small-group market. These employers will now have to comply with the actuarial value, cost-sharing, and essential health benefit requirements, which could add a 3% to 5% increase in premiums. Mid-size employers are…stuck between a rock and a hard place. The ACA is hurting the very group it was initially trying to help by taking states’ ability to set their own group sizes and rushing the transition of a small group from 50 employees to 100 employees. We look forward to working with members of Congress and the Administration on this critical issue and other needed improvements to protect insurance consumers.” For more information, visit

Efforts to Repeal the Cadillac Pick Up Steam
Unions, local governments, and representatives on both sides of the aisle are supporting a repeal of the Cadillac tax. A bipartisan majority of the House of Representatives has co-sponsored legislation to repeal the 40% Cadillac Tax on health plans. Two separate measures to repeal the 40% tax, authored by Rep. Frank Guinta (R-NH)  (H.R. 879) and Rep. Joe Courtney (D-CT)  (H.R. 2050), have attracted 224 House cosponsors. The Cadillac tax is a 40% non-deductible tax on the cost of employer-sponsored health coverage that exceeds certain thresholds.

Rep. Joe Courtney said, “Actuaries and health care experts agree that the 40% excise tax will unfairly impact a broad swath of American workers and their families, degrading the quality of health insurance coverage, and increasing out-of-pocket costs. The tax undercuts the goals of affordable and accessible health care. It is already affecting workers and employers as they plan for the next several years. With a bipartisan majority in the House already backing repeal of this tax—no small feat in Washington—and business and labor united to fight it, I am optimistic that this important fix is gaining momentum.”

Rep. Frank Guinta said, “I introduced H.R. 879—Ax the Tax on Middle Class Americans’ Health Plans Act—to repeal a harmful provision of the president’s healthcare law that will inflict a 40% tax on middle class Americans’ health plans. I’ve heard from many municipalities in my district that this tax hike will cost in the hundreds of thousands of dollars. In the case of our state’s largest city, Manchester, it will cost $6 million alone.”

Tom Flynn, political and legislative director for the United Brotherhood of Carpenters and Joiners of America said, “We commend Reps. Courtney and Guinta for their work to protect the employer-sponsored health plans of over 150 million Americans. We urge House leadership to move a stand-alone Cadillac Tax repeal bill as quickly as possible.”

Sallie Clark, president of the National Assn. of Counties Representatives said Courtney and Guinta have shown tremendous leadership in the bipartisan effort to protect employer-sponsored health plans. “Not only would the excise tax hinder our efforts to attract and retain quality employees, but it would also have significant impacts on county budgets and place additional burdens on taxpayers,” she added.

The 40% tax applies to plans sponsored by private sector and public sector employers, non-profit organizations, and even self-employed individuals. The tax penalizes employers that have employees with greater health care needs, workforces with higher numbers of older workers and employers based in higher cost areas, according to the Alliance to Fight the 40. For more information, visit

Judge Says that the House GOP Can Sue the President
The Los Angeles Times reports that House Republicans won the opening round in a lawsuit against President Obama over their claim that his administration spent money for health insurers under the Affordable Care Act without receiving needed approval by Congress. U.S. District Judge Rosemary Collyer ruled Wednesday that the lawmakers have the legal standing to sue. The Constitution “could not be more clear: ‘No Money shall be drawn from the Treasury but in consequence of Appropriations made by Law’,” she said, quoting a key provision. “Neither the president nor his officers can authorize appropriations; the assent of the House of Representatives is required before any public monies are spent.”

The judge rejected pleas by Obama’s lawyers to dismiss the House lawsuit on the grounds it involved a political dispute, not a legal one. Collyer said that the House claimed it would suffer an “institutional injury” if the president and his aides could spend money on their own authority. Her ruling is only the first step, however. She told lawyers she would hear arguments in the fall on whether the administration’s action violated the Constitution. If Collyer, a judicial appointee of President George W. Bush, were to decide in favor of the House on the merits, Obama’s lawyers would appeal to the U.S. Court of Appeals for the District of Columbia Circuit, where Democratic appointees are in the majority. From there, the case could move to the Supreme Court. Unless the dispute moves with unusual speed, a final decision might not come until after Obama has left office. Nonetheless, Collyer’s initial ruling is a victory for House Speaker John A. Boehner, and it is likely to be seen as endorsing the GOP’s view that Obama overstepped his authority. In a statement, Boehner said he was “grateful to the court for ruling that this historic overreach can be challenged by the coequal branch of government with the sole power to create or change the law. The president’s unilateral change to Obamacare was unprecedented and outside the powers granted to his office under our Constitution.”

The White House said it would seek an immediate appeal. “The law is clear that Congress cannot try to settle garden variety disputes with the executive branch in court,” said Deputy Press Secretary Jen Friedman. “This case is just another partisan attack — this one, paid for by the taxpayers — and we believe the courts will ultimately dismiss it.” Many lawyers saw the House suit as unprecedented. In the past, courts have regularly said lawmakers do not have standing to turn their political fights into legal battles. Last summer, when the House voted to sue Obama, many legal experts predicted the suit would be tossed at the first stage. Boehner had first alleged that Obama’s aides had violated the law when they waived several deadlines under the Affordable Care Act.

But more recently, the lawyers for the House focused on a little-known dispute over how to reimburse health insurers who take on more low-income policyholders. The Affordable Care Act said these insurers would be reimbursed for waiving copayments and other costs for these new policyholders, but it did not make clear whether this money would be provided automatically or instead would require an annual appropriation from Congress. So far, the administration has spent $4 billion, and the total spending is expected to reach $175 billion over a decade. After the Republican-led House refused to appropriate money, Health and Human Services Secretary Sylvia Mathews Burwell decided the reimbursements were mandatory under the law and could be provided despite the lack of an appropriation.

Law professor Jonathan Turley, the lead counsel for the House, said the judge’s ruling means the court will decide “an issue that drives to the very heart of our constitutional system: the control of the legislative branch over the power of the purse.” Despite the setback, health law experts do not see this case as posing a major challenge to the future of Obama’s healthcare law. If spending for the reimbursements were cut off, insurers might have to raise premiums somewhat. Other experts say the insurance companies could turn to a federal claims court to seek reimbursements. For the full article, visit

Online Refills Help Patients Adhere to Meds
Patients from all racial and ethnic minority groups who got prescription refills through an online patient portal had better medication adherences, according to a study in the Journal of the American Medical Informatics Association. “Our findings are consistent with other studies that suggest providing tools for health care management, such as online refills, can help improve health behavior such as medication adherence,” said lead author Courtney Lyles, PhD, affiliate investigator at the Kaiser Permanente Division of Research and assistant professor at the University of California, San Francisco.

According to a recent report by the National Institutes of Health, Americans with chronic conditions only take their medications as prescribed about 50% to 60% of the time. Poor adherence costs the health care system $100 billion to $300 billion each year, and results in about 125,000 deaths.

This study examined patients with diabetes from Kaiser Permanente Northern California who had been using My Health Manager. Patients who began consistently refilling their statin prescriptions online showed a 4% improvement in adherence. Those who used online refilling tended to be younger and were taking more recurring medications than those not refilling online. Also, they used the patient portal more frequently at the onset of the study. African-American portal users were less likely to use the online tool to refill their prescriptions, and all racial and ethnic minority groups had lower statin adherence compared to white patients at baseline. For more information, visit or

Sun Life Acquires Assurant’s Employee Benefit Business
Sun Life Financial is acquiring Assurant’s employee benefit business for $975 million. The transaction will create the sixth largest group benefit business in the U.S. The combined business will have one of the broadest product portfolios in the industry. The transaction is expected to close by the end of the first quarter of 2016. Dean Connor, president and CEO of Sun Life said, “The transaction will add significant new capabilities to the Sun Life U.S.” It will boost the company’s group benefit business including a strong dental business with the second largest proprietary provider network in the U.S. The transaction also includes a successful group life and disability business, and adds strong voluntary products and capabilities, vision products, and client technology. Also included is the disability RMS business, which is the leader in partnering with other insurers to offer disability products.”

The transaction will grow Sun Life’s in-force business by more than 50% to about $4 billion, strengthening the company’s partnerships with brokers and private exchanges and supporting investments in technology and distribution. Dan Fishbein, MD, president of Sun Life Financial U.S said, “This combination will enable us to offer one of the broadest arrays of employee benefit products in the market…Our portfolio will include leading capabilities in the group life and disability, dental and vision, stop loss and voluntary categories. Our increased size will also support future investments as we continue to grow our U.S. business.”

Upon closing, Sun Life Financial U.S. will provide protection through about 64,000 employers in small, medium, and large workplaces. The combined U.S. group benefit business will operate in multiple sites, including Sun Life Financial’s U.S. headquarters in Wellesley, Massachusetts and Assurant Employee Benefits’ main office in Kansas City, Missouri. For more information, visit

Patient Advocacy
CarePartner claims to have saved patients more than $255,000 in out-of-pocket costs over the past six months, simply by fighting through the system on behalf of patients. Patients pay a monthly fee for the subscription. For more information, visit

Dental PPO Plans
Concordia Dental now offers a low-cost, customizable product in 21 states and has expanded the availability of two popular PPO products.  The new product, Smile for Health–Basics Plans, is available in Alaska, Arkansas, Arizona, California, Colorado, Iowa, Idaho, Kansas, Kentucky, Massachusetts, Missouri, Montana, New Jersey, Oklahoma, Oregon, Pennsylvania, South Carolina, South Dakota, Texas, Utah, Wisconsin and Wyoming. It includes two plans with customizable deductibles and maximums to meet varying employer needs. The plan covers preventive, restorative, and major dental services. It offers optional coverage, such as vision and orthodontics. The plans also include enhanced dental benefits for people with gum disease and certain chronic conditions, such as diabetes, heart disease, and stroke. For more information, visit

Health Plan Selection Tool
NerdWallet is offering health navigators, a concierge service enabling working Americans to maximize their health care benefits. Personalized for individual companies, Health Navigators combines a health insurance selection tool, pertinent content, and dedicated medical billing experts. NerdWallet personalizes the Web-based application for each individual company, populating the tool with the company’s health insurance options. By answering a few simple questions, employees can find targeted suggestions for choosing a health insurance plan for their situation in less than five minutes. For more information, visit

Mobile-optimized Financial Planning has been redesigned. It now offers a highly engaging resource for planning, pursuing, managing, and reaching financial goals. Original educational articles, videos and calculators are organized on by the following goals:

  • Planning for college
  • Protecting finances from the unexpected
  • Caring for a loved one with special needs
  • Protecting those who matter most and planning for the financial future
  • Planning for retirement and long term care, and managing income in retirement

Resources are also available on for businesses.

Annuity Webcast
The National Assn. of Fixed Annuities is holding a webcast Thursday, September 24
At 8:30 a.m. PT. It will explore the complex consumer behavioral reactions associated with annuity purchases. For more information, visit

Employees Need Customized Benefit Communications
A survey by The Guardian reveals that employees prefer benefit communications that are customized to their needs. Early entrants to the workforce (those within the first five years of working) want more choice and education in the workplace. Near-retirees (those within five years of retirement) value their benefits and worry about losing them in retirement.

Early entrants have a strong desire for financial education and guidance to help them focus on their immediate financial needs, such as paying bills, job security, work/life balance, and reducing debt. Nearly two-thirds of these younger workers say that buying insurance and saving for retirement through their employer is easier than doing it on their own, and 56% prefer learning about financial planning and products at work compared to 44% of those near retirement.

Near-retirees are most concerned about maintaining adequate health insurance, having a comfortable retirement, staying healthy, and having enough savings. While 93% of respondents in this age group say that it’s important to have retirement savings that last as long as needed, only 62% say they have achieved this goal.

Sixty percent of all employees say that their benefit meetings would be more relevant if they were targeted by age. Those within the first five years of working need more personal advice during enrollment. If employers increase access to education and advice, it can benefit the nearly 70% of early entrants who say that it is very important to find a trusted source of financial advice. Unfortunately, only 33% of employers place high importance on tailored communications, and only 13% have implemented such an approach. For more information, visit

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