Top questions for your insurance provider, plan broker or advisor

  • Can you provide details on drug, health, and dental benefits utilization which impacts my health premiums?
    • Can you provide a detailed breakdown of our overall drug costs and which medications/diseases are having the greatest impact in our workplace?

      Are we seeing growth in the number of claims and cost per claim? If so why?

      How will our current paramedical practitioner costs (physiotherapy, chiropractor, massage therapy) impact our overall health plan premiums?

      How does our paramedical usage compare to the averages you see?

      Are there steps we can take to improve our plan efficiency in these benefits?

  • Are we part of a Preferred Pharmacy Network (PPN) which can help lower my overall drug plan costs?
    • Do you offer a PPN that can help lower the cost of a prescription such as negotiated lower mark ups for specialty medications, if so how much can we save?

      For certain chronic disease medications do they offer larger fill volumes reducing the need for monthly refills?

      What is the availability of pharmacies in the network vis-à-vis plan members’ residence? Are there pharmacies nearby for all plan members? Will plan members have to travel farther to pick up their medications?

      Is there an exception process for a plan member who won’t or cannot change pharmacies?

      How will the PPN be communicated to plan members?

      What tools are available to plan members to find a PPN pharmacy?

      How much can we save? How will cost savings be measured?

  • Is our plan mandatory generic?
    • How will plan members currently taking a brand name drug that has a generic alternative be handled? What is the exception process?

      How will plan members with a prescription for a brand name drug that has a generic alternative be handled? Is there an exception process?

      What are the potential savings?

      How many plan members could be impacted?

  • Which drugs require prior authorization and why?
    • What are the criteria based on? Clinical evidence? Cost?

      What are the potential savings of prior authorization?

      What is the impact of not implementing prior authorization?

  • Managed formulary
    • What are the preferred treatment options?

      What evidence was reviewed to support the recommendations?

      What costs and benefits were considered when comparing medications to choose the preferred one?

      What communication tools are available for plan members and their physicians to understand what is covered by the managed formulary?

      How often will new drugs be reviewed?

      How will decisions on new drug covered be communicated? Will the rationale for coverage decisions be shared?

      Who manages the formulary? What qualifications do they have?

      What savings will the formulary offer my drug plan? How is the value of the managed formulary assessed? How will actual cost savings be measured?

      Is there an exception process available for plan members? How does this work?

      When the managed formulary is being introduced for the first time, will plan members who are currently being treated with medications that are not on the preferred drug list, will they be grandfathered?

      Will drugs ever be removed from the formulary or moved to a lower tier with reduced coinsurance? How will this be communicated? How will members currently taking these drugs be handled?

  • Maximums and annual caps
    • Are we limiting medication access to the patients who need the medications the most?

      Are there other types of plan designs or underwriting arrangements that could be considered for a similar cost?

      What are the potential savings?

  • Will the new program recommend plan members switch from the drugs prescribed by their doctor?
    • What evidence will be used to support the switch?

      How will this be communicated to the pharmacist, physician and plan member?