Prescription Drug Coverage

I take a number of prescription drugs and I would like to find out which plan would cost me the least out of pocket cost. Is there a way to do this?

Our results comparing plans include substantial drug costs, both name brand and generic. So you probably don't need to do much more homework. You should look in the Guide for cost sharing and see which plans pay best for drugs and how much you can save by using generics or by using mail order. If you take one or two very expensive name brand drugs, we would also recommend that you select two or three plans that look good to you for both overall costs and drug costs, and then use the websites for these plans to check the formularies to see if your drugs will be covered. That should lead you pretty quickly to the plan or plans that will work best for you. Don't forget to set up a Flexible Spending Account to help pay for your share of costs.

I need to choose a plan that is the best to cover the cost of my cancer medication that I receive once a month at my oncologist office. The drug is called Somatuline Depot and its cost is $10,400 monthly at present. I will be on this more than likely for the rest of my life, unless they are able to come up with a better option.

There are several ways to nail down which plan will work best for you. First, each plan’s website has an online formulary. They are not all equally easy to check but look at several to see if you find coverage for your drug. In terms of language used in health plans, it will be a "specialty drug." If you find a positive entry, you should still call a plan representative (and maybe do so two or three times) before you select that plan. Second, your physician should be able to tell you what health plans cover that drug. Be careful if you are told something like "United" because United and Aetna and several other companies have different formularies in different plans. You want to nail down that it is one of the PSHB plans that you are told does cover the drug. Again, call the plan to confirm. Third, there are probably online user groups with your condition. Find one or two of them and see if you can get advice from some other federal employee (or others, perhaps) as to what plan or plans cover this drug and if there are any problems. Again, you need to confirm before enrolling. If you find a couple of plans cover the drug in ways that will work for you, review their other benefit details, including their cost to you for "specialty drugs" and their catastrophic limit. Finally, be sure that your doctor is covered in the plan you select. The plan’s also have provider directories online and you can ask the providers and/or call the plan to double or triple check.

I have multiple sclerosis and am on the specialty drug tysabri. We are switching from my husband's plan to my federal health insurance plan. I am looking for a family health plan that works well for people with chronic health conditions. Do you have any recommendations for plans?

It will be treated as a "specialty drug" in all PSHB plans. Each plan has its own formulary status, pre-approval process, and cost to you for this drug. What we recommend in cases like this is that you confer with your physicians and your pharmacy and perhaps online user groups to obtain their advice on these key questions: what plans cover this drug and of those which ones work best for the patient in terms of cost and red tape? If you have Medicare Part B, ask if that makes a difference in what you will pay. Depending on what you learn, download several plan brochures and study the drug benefits (search the brochure on "specialty drugs"), visit those plan websites to see formulary information, and call those plans. Try to nail down how you will be treated in plan X versus plan Y. Then choose your plan. You should ignore the "average" cost column in our ratings and focus on the "most you can pay column." A fair number of plans hold overall costs, including premium, below $10,000 a year for covered services. If many cover your drug well, you can make your final choice depend on other factors. If you aren't yet retired, you should also set up an FSA in the highest possible amount to get a roughly one-third reduction in your out-of-pocket costs.