How to Navigate New Pharmacy Benefits

When switching to a new pharmacy benefit plan, employees can feel a sense of dread: will my current medications still be covered? How much? Where? These are all valid concerns for anyone using prescriptions on a regular basis.

Thankfully, Sona Benefits has years of experience helping members and businesses transition smoothly to their new pharmacy coverage. Our Account Managers have a front-row seat to the questions and concerns members have when navigating their new pharmacy benefits. Our team put together the best questions members can ask and steps they can take when using their brand-new pharmacy benefits:

Steps to Take:

• Be a Part of Open Enrollment
  • Open Enrollment is a fantastic time for members to ask specific questions and review what medications are covered in certain drug classes. Your Pharmacy Benefits Manager (PBM) should have a team dedicated to answering these questions and walking members through the enrollment process to ensure that there are no gaps in medication coverage. They can also use this time to discuss any changes to the plan, such as which medications are now preferred vs. non-preferred.
• Ask about Specialty Drugs and Patient Assistance
  • Does your brand name drug or specialty drug have a high copay? Many brand name and specialty medications have copay assistance available. These programs run in conjunction with your pharmacy plan and help reduce members’ out-of-pocket costs. Patient assistance programs are often available for many specialty medications. These programs are for members who may not have coverage or may be having trouble affording their specialty medications. Your Account Management team should be able to assist members with both of these processes.
• Be Prepared for Prior Authorizations
  • Some medications may require a “Prior Authorization” (PA), meaning that they require review by both a physician and pharmacy team before being filled. The drug may also require step-therapy or specific treatment plans before coverage through the plan can be determined. This process requires the prescribing provider to send documentation to the PBM’s clinical team. Once notes are received, your PBM will review the notes and inform the provider and pharmacy of the determination. If you are aware that your medication has required a PA in the best, reach out to your PBM so they can proactively gather the necessary documents on your behalf! This helps prevent any medication gaps and allows members to stay adherent through plan changes.

Taking these steps and asking pointed questions can help ensure that members have the smoothest, most enjoyable experience!