Prevent Sticker Shock at the Pharmacy—The One Question You Should Ask Before You Fill Your Next Prescription.

We’ve heard the stories of drug manufacturers charging hundreds of dollars for a single course of treatment. Two years ago, Mylan CEO Heather Bresch found herself the center of a congressional hearing about her company’s decision to increase the cost of the EpiPen. Just one example of many high priced drugs, Americans report that they struggle to afford the cost of brand name drugs at a rate of one in four. What can we do?

Despite our wishes, bringing a new drug to market in the United States is very expensive. Between research, innovation, testing and FDA approval, the process can take years and cost millions, so it’s to be expected that drugs will be protected for several years by a patent. During this time, the drug manufacturer is aiming to recoup its investment and make a profit.

But patents end, and that’s why the one question patients need to ask their doctors is if there is an acceptable generic alternative. You might be surprised to know that 80 percent of brand name drugs on the market today have generic versions. Generic drugs work in the same way and provide the same clinical benefit as the brand name. They’re also approved by the FDA just as the brand name drug was years earlier, but at a significant lower cost because the research, innovation and testing need not be repeated.

What’s the difference in cost between brand name and generic?

According to the IMS Health Institute, generic drugs saved the American health care system $1.67 trillion from 2007 to 2016. How? A generic alternative is typically 85 percent less expensive than its brand name. And that cost savings is passed down to health insurance companies and, ultimately, patients.

Most health insurance plans have prescription drug tiers listed on their member ID cards. Often, you’ll see tier one is in the $5-30 range for a 30-day supply, while tiers two and three rise rapidly. (It’s important to note that some carriers have as many as five tiers, but that’s not the norm.)

How do you know which tier your drugs fall into?

The health insurance company provides a drug formulary that members can review. Not exactly practical to do while in your 20-minute physician appointment, but you can also ask your doctor. They often have a great deal of knowledge about the drugs they prescribe and can alert you if the drug is likely to be in a higher tier before you head to the pharmacy.

In some cases, there is no generic version of the drug being prescribed. But it doesn’t always mean you have no other option other than to pay a high tier copay. Most drugs fall into a class where there are several drugs designed to treat the same condition. While the newest drug might be all the rage, there is often an older drug that has years of proven efficacy that you can try first.

Bottom line…take control of your health care costs and ask your doctor if there is a generic drug that may provide the clinical benefit you need.

If you happen to face a situation where the only viable option is an expensive brand name drug, resist the urge to avoid treatment due to high cost. Most drug manufacturers offer rebates, discounts and financial assistance to Americans who can’t afford their prescription medication. Ask your doctor or the pharmacist for more information about how to apply.

We’re fortunate to live during a time of great medical innovation. We’re living longer lives as a result. So while there is much debate about the high costs of prescription drugs, we can find solace in knowing many conditions that were fatal or diminished a great quality of life in the past are now very manageable.

Have additional questions about your prescription drug benefits? Please talk with your human resources department or your PBG representative.

Understand Your Health Plan Before You Go to the Doc—A New Year Resets Deductibles and Out-of-Pocket Maximums.

It was recently estimated by the National Business Group on Health that the total cost of health care (including premiums and out-of-pocket costs for employees and dependents) would rise to an astounding $14,800 per employee this year. After surveying 170 large U.S. employers, the results suggested that employers would cover approximately 70 percent of those costs, while employees would pay 30 percent. As employee benefit advisors, Partners Benefit Group sees similar statistics among employers in Georgia and the Southeast.

Obviously, it goes without saying that health insurance continues to be a significant expense for employers and employees, so maximizing its value is essential. With a new year upon us, most health plans have hit the proverbial reset button on deductibles and out-of-pocket maximums. Let’s review these important aspects of health insurance to empower ourselves to make wise health care choices.

Deductible: The deductible is the amount you pay for health care before your health insurance policy pays anything. According to widely-reported data, the average deductible varies between $1,500 for single coverage to as high as $8,000 for high-deductible plans. While many people will not use their health plan enough to satisfy the deductible, it is wise to plan that such an event could occur, especially if you have from more than one plan to choose.

Coinsurance: Once the deductible is satisfied, you share health care costs with the insurance plan by paying coinsurance. Coinsurance is a percentage. It’s common to see an 80/20 or 70/30 health plan, which means that the health insurance company will pay 80 percent and you will pay 20 percent of health care costs.

Copay: Most people are used to paying copays for certain health care events like office visits and prescriptions. They are often tiered. For example, visiting a specialist often carries a higher copay than visiting a general practitioner. Where confusion often sets in is when your physician orders further care or testing. Lab work is one such example. Because this falls outside your office visit, the services are subject to the deductible. Knowing this ahead of time allows you to question your physician about the medical necessity of all ordered tests, as well as verify that service providers are in your medical plan network. 

Out-of-pocket maximum: Most plans carry a maximum amount you’ll pay during the plan year. After the amount is satisfied, any further care is paid 100 percent by the insurance plan. Keep in mind that copays and out-of-network providers may be excluded.

There’s good news…

All Affordable Care Act plans include a list of preventive care services that are covered 100 percent by health insurance as long as you go to an in-network provider. Considering these services are designed to keep you healthy, be sure to take full advantage. For a complete list, click here. Also, check with your health insurance carrier about any financial incentives it may offer for completing health assessments, getting flu shots, etc. Many offer generous rewards that may help pay for future health care expenses.

Have additional questions? Please talk with your human resources department or your PBG representative.

Some Health Insurance Providers are Paying Members to Stay Healthy—Are You Maximizing Health Insurance Incentives?

Employers and insurance carriers alike are urging Americans to make wiser lifestyle choices that directly impact our short- and long-term health. While it’s obviously a good idea to stay active and take advantage of preventive health screenings, some Americans need a little more encouragement.

Health insurance companies have long offered discounts on fitness club memberships, telephonic access to nutritionists and access to monthly wellness tips. For example, Blue Cross Blue Shield of Georgia offers discounts to its members for a wealth of healthy living resources including weight loss programs and stress reduction services such as acupuncture, massage and chiropractic visits.

But some carriers are going further.

Ambetter of Peach State launched My Health Pays™ to its members, which offers reward dollars to those who choose to take charge of their health. The rewards add up quickly with $50 automatically pre-loaded to a rewards card after a member has their annual preventive exam. There’s other opportunities to add to this balance and rewards can be used to help pay for healthcare costs such as monthly premium payments, doctor copays, deductibles and coinsurance.

Carriers also continue to promote healthy weight as their priority initiative and with good reason. John Cawley, a professor of policy analysis and management at Cornell University released research this year that provides real insight on how individual states are affected by the health care costs of obesity. In 2015, North Carolina, Ohio and Wisconsin spent over 12 percent of all health care dollars to treat obesity-related issues such as diabetes and heart disease.

The intent behind offering discounts and rewards to be proactive in managing health is clear—healthier members have fewer and lower health insurance claims, which directly affects an employer’s premiums and often the share employees pay.

As an employer, how can you encourage employees to take full advantage of the health insurance benefits and incentives?

Wellness emails and payroll stuffers are traditional methods of communication, but some employers are getting creative and choosing certain weeks to emphasize goal-based behaviors. For example, they’re offering extra time away from work for employees who get their flu shots. A short, scheduled disruption from work is far easier to absorb than an unexpected week off when employees come down with the flu and, of course, there’s no claim to the health plan, which may keep premium hikes at bay.

Call or talk to your PBG representative for more information.

Planning For the Unthinkable—How Much Disability Insurance Do You Really Need?

New GoFundMe campaigns continue to be on the rise lately. If you’re active on social media, you likely scroll past them fairly often. This might suggest that more people are falling ill or getting injured at higher rates than before. But that’s not really the case. Rather, it’s Americans are still more likely to invest in life insurance than disability insurance, which leaves them unprepared to weather the financial loss when out of work. And, this is a conundrum for insurance advisors.

Many Americans know the statistics—we’re more likely to become disabled during our career years than we are to pass away. While it’s advisable to purchase life insurance to protect your family in the event of death, we need to do the same in case we fall ill or are injured.

In a recent Forbes article, we learned the Social Security Administration reported that 85.6% of men and 91.2% of women will survive to at least age 67. In the same report, it was projected that a 20-year-old man has a 26.8% chance of suffering a 12-month or longer disability. Those aren’t favorable odds, and that’s a long time to go without any income no matter your age at time of disability.

The Council for Disability Awareness released some startling statistics that should bolt Americans into action. It says:

  • More than 51 million working adults in the United States don’t have private or employer-sponsored disability insurance.
  • Only 48 percent of American adults have enough savings to cover three months of living expenses, while 52 percent have less or none at all.

Three moves to make right now to protect your family in the event you become disabled:

  1. Buy long-term disability insurance first; short-term second. If you become disabled, the Council for Disability Awareness reports the average time away from work is nearly three years. You’ll need the lengthy coverage.
  2. Buy more insurance than what your employer offers as part of your benefit package. You can often buy it through your employer, but private disability insurance stays with you should you change jobs.
  3. Work with a professional advisor who can help you realistically estimate the benefit you need to maintain your financial lifestyle if disabled.

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