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Health insurance law may dramatically affect pharmacists, patients

Health insurance law may dramatically affect pharmacists, patients

A tough pill to swallow?

January 5th, 2014 in News

Amanda Rudder, managing pharmacist at Whaley's East End Drug, sorts prescription medication Friday morning. Some patients may see changed prescription coverage with changed plans.

Photo by Kile Brewer/News Tribune

Editor's note: This is the third in a series of stories that will explain the 10 essential health benefits required under the Affordable Care Act and explore what effect those requirements will have on patients and caregivers.


Some Missouri pharmacists say the Affordable Care Act (ACA) will not only affect patients' prescriptions, but also the way pharmacists perform their jobs.

"(We expect) increased time in having to communicate with physicians on non-covered medications," said Stacy Welling, president of Whaley's Pharmacy. "(We also expect) increased communication with plan administrators in gaining knowledge and information on covered medications, exception processes and deductible usage."

Prescription drugs are one of 10 essential health benefits required for health insurance plans to cover under the ACA - also known as Obamacare.

"I think that's really crucial for people because they're going to have drug coverage now that they didn't have in the past," said Jack Fincham, a pharmacist and professor at the University of Missouri-Kansas City School of Pharmacy.

More than 2 million Americans gained health insurance Wednesday through the ACA's Health Insurance Marketplace. The Obama Administration hopes to have 7 million Americans enrolled by March 31, the last day of open enrollment.

How do ACA prescription drug plans work?

Fincham - who has taught pharmacy for 30 years - said he deals a lot with health care, health care reform and patient compliance.

"My perspective is more from a policy standpoint, rather than from a day-to-day, taking-care-of-patients standpoint," Fincham said of how the ACA affects prescription drugs.

He said each health insurance plan is required under the ACA to provide a patient a preferred drug list.

"These are the drugs that are covered under a specific plan, and in many cases, these plans will put forward a formulary that's accessible to patients," he said. "These formularies allow people to see what drugs are covered within a particular plan, so that they can work with their physicians on what might be the best drugs for them to be taking."

He said plans include categories of prescription drugs.

"Within the various drug categories, there are drugs for hypertension, drugs for diabetes," Fincham said. "Each of these plans has coverage for a drug in each of those classes. Now, the plan may not include drugs people currently take, so they might have find a similar type of drug that they haven't taken before."

Fincham said most plans will have some sort of copayment.

"In some cases, people with Medicaid have no payment costs whatsoever," he said. "Apart from that, there's some people who have insurance for prescription drugs, through their employer, or whatever. If the drug is on a preferred list, there may be no copayment for the prescription medication. I'd say it's pretty rare, but it does happen."

He said about 72 percent of patients pay or will pay a copay of $10 or less for prescription drugs.

"That's good if you're in that 72 percent, but close to 30 percent are paying quite a bit more," he said. "But, at least they have some coverage."

He said people - especially that 30 percent - will have to make tough decisions regarding prescription drugs, what they take and how they take it.

"It's not easy for a lot of people," Fincham said.

What do pharmacists expect?

Christian Tadrus, president of the Missouri Pharmacy Association, said there are still a lot of unknowns in terms of how the ACA will affect prescription drugs and pharmacies.

Tadrus is a pharmacist and owns three independent Sam's Health Mart pharmacies - two in Moberly and one in Fayette.

"What we do expect is that this is going to mimic what happened several years ago when Medicare started the Part D program," he said. "Medicare Part D was sold as a way for seniors to have access to prescription services that were never covered in Medicare before."

He said Medicare Part D brought confusion into community pharmacies, much like the month of January does every year. He expects no different with the ACA.

"Most people are coming on to new programs, and their processors are set up, but their data is not in the system yet," he said. "The pharmacies end up having to deal with the headache of processing a prescription and then getting a rejection from the insurance that says "patient not covered,' even when the patient has payed their premium."

He said with the implementation of Medicare Part D, pharmacies ended up carrying patients for quite a while until the databases got updated and the confusion was worked out.

"We kind of anticipate that a little bit with the ACA this month, where people have signed up for what they have, or maybe they've been dropped but didn't know they had been dropped from their existing plan that is no longer going to be offered this year," Tadrus said. "The real world from the community (pharmacy) side is going to be that we still have to take care of the patient and make sure they can get the meds they need, even if they have to pay out of pocket or the pharmacy has to carry them."

Advice for picking up a prescription

Tadrus advises patients to be patient when picking up prescriptions, regardless of whether their insurance plan is from the Marketplace or not.

"Don't get frustrated and (do) ask questions," he said. "Pharmacies aren't going to let a patient go without their medications. Remain calm if it (insurance) doesn't go through, initially."

Fincham said he has always told patients - when he's been in practice - to question and challenge everything.

"I think more and more physicians, certainly pharmacists, nurses, want patients to be their own best advocates," he said. "The way to do that is to ask more and more questions."

He also encourages patients to help their pharmacists help them (the patients) make decisions.

"The pharmacist can work with the physicians, and they can work with patients to see what can be done to help them (patients) as much as possible," he said.

Your questions

The News Tribune received several questions about the ACA:

Q: What is the deadline for someone who signs up now?

A: According to, "if you enroll between the 1st and 15th day of the month and pay your premium, your coverage begins the first day of the next month." The final day to enroll is March 31, 2014, for coverage that begins May 1, 2014.

Q: Is Missouri Medicaid going to be expanded?

A: The Missouri Legislature decided during the 2013 session that Medicaid would not be expanded in Missouri. The option is still on the table for 2014. Although, when someone applies for coverage on, the system will determine if the individual is eligible for the state's current Medicaid program.

Q: How does the tax credit work in the Marketplace?

A: According to "Advance payments of the tax credit can be used right away to lower your monthly premium costs. If you qualify, you may choose how much advance credit payments to apply to your premiums each month, up to a maximum amount. If the amount of advance credit payments you get for the year is less than the tax credit you're due, you'll get the difference as a refundable credit when you file your federal income tax return. If your advance payments for the year are more than the amount of your credit, you must repay the excess advance payments with your tax return."

Q: I've been booted off of several times and have already sent in my paper applications. What should I do next?

A: Many of the website glitches on have been fixed, and nearly 1 million Americans signed up for coverage in December, prior to the Dec. 24 deadline for coverage that began Jan. 1. You can wait to hear back regarding the paper applications and continue trying to access the website.

Do you have questions?

We want to answer your questions regarding the ACA; email reporter Olivia Ingle at or call her at 573-761-0248.

Also, feel free to share your experiences with the ACA or your experiences signing up for coverage in the Marketplace.