Health, Doctors and Common Sense

If you have questions about the practices of your managed-care coverage, ask the experts at the state Department of Managed Health Care.

My health plan allows only a $2,700 cap on coverage for my medications. However, just for the month of January, the cost was $704, so I will never make it to the end of the year. I showed one of my doctors the price for a generic medication, and he thought the price was way out of line. I am so confused. I have changed all my meds to generics and use the mail-order pharmacy, and yet I still cannot manage. Where are these $4 prescriptions that I keep hearing about? I have fibromyalgia, so I do take several medications, but I sometimes just want to stop all of them.

– Marsha in Modesto

You are not alone in your confusion. In California, there are many health plans, and each health plan has different types of coverage designed to meet the needs of a diverse consumer base. Although we would need more information from you to be certain, it sounds like the health plan product you have selected is not going to meet your ongoing needs.

Most health plans require some kind of qualifying event, such as the loss of a job or a change in marital status, before you can switch products outside the open enrollment period. However, that shouldn't stop you from contacting your health plan's member services department and asking it about other types of plans that are available to you. Explain your situation and your concerns, and there's a good chance that they'll have a plan better suited to meet your specific needs. Ask questions now so that when open enrollment does arrive, you'll be ready to switch plans if you need to.

There are $4 prescription programs out there in some retail-store pharmacies, but not all medications or dosages are included in these programs. In fact, most of the prescriptions included are the most common and least expensive medications. While these programs are a great benefit to a lot of consumers, the types of medication are limited. Contact your local pharmacies directly and ask if any of your medications are included in the program.

Another option you should explore is whether your health plan's mail-order prescription service offers 90-day supplies of any medications that you will be taking for an extended period. The co-pay obligations are generally lower when you order a 90-day supply through the mail.

One other option is to check with an online prescription drug assistance site. There are several sites on the Internet that can show you how to receive medications at steep discounts, but with most of these sites, you have to fall below certain income levels to qualify.

Consumers needing assistance with their health plans can call the Department of Managed Health Care toll- free at (888) 466-2219 or log on to www.healthhelp.ca.gov.