Should old prescriptions be forgot,Most of you probably know that "formularies" are lists of drugs approved by health insurance companies for partial or full payment "under the terms and conditions of the coverage." Each insurance company has its own formularies, which they change every year on January 1 based as much or more on monetary concerns as on medical ones.
And never brought to mind?
Should old prescriptions be forgot,
At formulary time?
So, now that Medicare Part D Season is coming to an end, it's time to prepare for that overlapping health insurance "holiday" - formulary time! Senior citizens have the privilege of "celebrating" both!
Auld Lang Syne is at least 250 years old, so some of the lyrics do sound a bit "peculiar" to the modern ear. My parody, Formulary Time, follows the same odd patterns and rhymes as its inspiration. After a "cup 'o kindness" or two, it makes nearly as much sense as the original!
Wander with me for a while in auld formulary world to be (hopefully) educated and entertained and to share your formulary stories with everyone.
Although meant for pharmacy students, Making Sense of Medicare Part D - Drug Plan Formularies provides anyone an excellent introduction to the world of the formularies. It explains terms such as tiers, co-payments, prior authorization, step therapy, and quantity limits - all facets of every formulary. Additional key concepts:
One of the most difficult portions of the new Medicare Prescription Drug Plan to navigate is the various drug plans' formularies. Selection of a plan is based on what drugs you are on and which plans provide the best coverage for your selected drugs. In order to select the optimal plan for themselves, it is critical that Medicare-eligible individuals understand how these formularies work.Yes, and those Medicare Part D beneficiaries better also be aware of what's in this article, reported by the San Francisco branch of the Gray Panthers and numerous other sources:
However, because of the ability of the insurance providers to negotiate their own "deals" with the drug companies under Medicare Part D, without having to pass the savings on to the consumer, formularies often contain the drugs that these insurance companies are able to negotiate the best pricing on.
There is one important catch with Medicare Part D that Medicare beneficiaries must be aware of. Once a Medicare Part D beneficiary chooses a plan they are "locked in" to that plan for the year. Now, even though the beneficiary has done all the research to choose the right plan that covers all of their drugs the insurance companies have the ability to switch which drugs are covered under their formulary (with a 60 day warning period).
The number of medications covered under Medicare prescription drug plans offered by the 10 health insurers with the largest enrollment will decrease next year by 26%, according to a recent analysis by Avalere Health, USA Today reports. (See below. According to the analysis, the number of medications covered under Medicare prescription drug plans offered by UnitedHealth and Humana next year will decrease by 30%, from more than 3,750 treatments to more than 2,620, although the plans will continue to have some of the largest formularies available.The complexity of the situation is further demonstrated by the numerous formulary-related computer programs such as Fingertip Formulary, Epocrates, and RxPlan. Formulary decision-makers may turn to such magazines as Formulary Journal, and Drug Formulary Review. Those who hope to influence them have their own resources, including training classes, as reported in Equipping your Sales Force to Influence Hospital Formulary Decision-Makers. There are, of course, thousands of books on the subject as well.
There is surprisingly little consumer information available online about formularies. Most of it is links to formularies for specific providers (such as this for one of the Highmark plans), guides for Medicare participants (that typically point to this government site), and fluff from vendors hawking healthcare insurance products.
I don't want to turn this into another piece on Medicare Part D, but Part D and formularies are two sides of the same coin. It's beyond unfortunate that those who are arguably affected by formulary changes the most - senior citizens - turn en masse for guidance from the AARP. Actually, it's more like a crime. AARP only pretends to be a friend of the elderly and any information provided by that organization is suspect at best. AARP not only pushed hard for Medicare Part D, it is profiting from it enormously. I highly recommend the article AARP is drug plan advocate, marketer, originally published by the Philadelphia Inquirer. A few money quotes:
The AARP plans often cost hundreds of dollars more a year than the lowest-priced competitors. ~ That kind of loyalty has pushed the AARP-branded plans to the top of the Medicare heap. ~ The group makes millions from lending its name to Medicare plans. ~ Trust plays a big role in picking a Medicare plan. ~ The array of choices overwhelms even many experts. ~ ...[AARP] has risen to the top because of its reputation as a champion of people age 50 and over. ~ Premiums among the nation's top 10 plans are rising about 21 percent in 2008, and insurers are placing more restrictions on what drugs they will pay for... ~ While its cachet comes from advocacy, AARP is also an entrepreneurial juggernaut that profits from the Medicare drug benefit it helped pass. ~ The Washington-based nonprofit crossed the $1 billion mark in revenue last year. ~ Medicare used to be a quiet market where few needed to advertise. Now it can be an endurance test... ~ Even many advisers say they cannot choose without help. They often work by running a client's drugs through a public program at www. medicare.gov... ~ The federal Web site can be wrong or slow to update... ~ Modeling the needs of a typical patient... ~ The cheapest AARP plan was 33rd... ~ ...the [AARP] cost can be $500 to $700 more a year.While the pharmaceutical and insurance companies are jumping for joy with record-breaking profits, the rest of us are jumping through hoops. A few personal anecdotes from me illustrate some of the formulary problems. I invite you to share your own formulary stories in the comment section.
My husband was uninsured for seven of the eleven years he battled serious illness. During that time, he was successfully treated with drug A for one of his conditions. He finally got insurance, but with very limited prescription coverage - so limited, in fact, that one refill of one of his medications used up his entire quarter's worth of benefit. Drug A was part of the company's formulary in year one. The second year, it was on the formulary again, but as a "step therapy." The doctor could not even write for Drug A until my husband endured a month of Drug B and the doctor wrote a letter stating why he indeed needed Drug A. This was EVEN THOUGH THE INSURANCE COMPANY WOULD NOT BE PAYING FOR IT! Year three, Drug A was inexplicably on the formulary again with no restrictions and Drug B remained. Year four, Drug A was not on the formulary at all. Drug B was also gone. Thankfully, a new Drug C was on the formulary that did help as much as Drug A had.
Multiple this chaos times the nine drugs my husband took regularly.
A few months ago, I finally got health insurance for the first time in seventeen years. I am grateful to have it, especially because drug coverage is included, since I take four expensive life-saving medications. However, right off the bat, two of them had to be changed because they were not on the formulary and a third required letters and phone calls from my doctor before she could prescribe it. I am not authorized to have the blood work yet which will reveal whether the two switched drugs are working. No matter. I received a copy of the 2008 formulary in November. Two of the four drugs I am on now are no longer on the formulary!
Multiply this lunacy times millions of patients taking thousands of drugs.
In November, the local mom and pop pharmacy demonstrated common courtesy and good business sense by calling every single regular customer, including me, to warn them that there would be major formulary changes and reductions on January 1. They sought permission to fill every prescription they could before the new formulary takes effect. This was extremely helpful to me and not only did the drug store ring up as many sales as possible, they avoided at least some of the problems they will surely encounter starting January 2. My doctor's office also called me last week to change one of my scheduled appointments in January. Instead of seeing patients that day, she will be attending an out-of-town educational seminar on the new formularies. When she returns, she will then have to train the other doctors in the practice and her staff.
Multiply this insanity by thousands of pharmacies, hospitals, and doctors.
Human lives and billions of dollars are at stake. The time and money spent attending to formulary issues is wasted instead of being used for actual patient care. The stress to patients, their families, and their healthcare providers is incredible - and unnecessary. It's not a game, except to the profiteers. The rest of us are being manipulated by this formulary madness.
Well, I don't know about you, but I'm certainly ready for a song!
I was amazed to find that Auld Lang Syne has a rich history as much more than just a song for New Year's Eve. In different parts of the world, it is played and sung at weddings, graduations, and funerals, and it has even been used as a national anthem. There are many variations on the lyrics. Try this particularly fun set at your next New Year's Eve party:
Should auld acquaintance be forgot,
And never brought to mind?
Should auld acquaintance be forgot,
And days of auld lang syne?