Drug Formularies

If you belong to a health maintenance organization (HMO) or your employer offers its own health insurance plan, chances are it uses a prescription drug formulary to maximize the effectiveness of its pharmacy benefits program.

A formulary is essentially a preferred drug list for a particular health

plan. The drugs on the formulary have been evaluated and researched for safety and effectiveness, and are often the most cost-effective versions of commonly prescribed medications. By using a single set of prescribed medications for most routine

treatments, health plans are able to provide high quality care and keep costs as low as possible.

Formularies are not static lists; they change as new drugs and research become available. Usually, doctors and pharmacists review medical and pharmaceutical literature when deciding which drugs to place on a formulary. Some insurers allow variation from their formulary in specific instances, while others charge members a much higher copayment for medications that do not appear on the formulary.

Here is some basic information about a drug formulary:

• It is a comprehensive list of drugs expected to meet the needs of most patients.
• It is used as a way to provide cost-effective prescription drugs to members.
• It consists of both brand and generic drugs that have been approved by the health plan’s panel of physicians and pharmacists.
• It enhances the quality of medical care by identifying the best medicines from among the thousands available. It is also a tool to address skyrocketing prescription drug costs.
• Formulary drugs are chosen for their safety, effectiveness, quality and cost.

To find out about your health plan’s formulary, talk to your company’s human resources representative.

Generic vs. Brand Name

Some people think that generic versions of their prescription drugs are inferior, but the FDA requires that generic drugs meet the same standards as their brand name counterparts.

The difference between the two involves the research, development and marketing investment that went into the original brand name product. When “generic equivalents” become available, they have the same active ingredients and chemical purity as the brand-name drugs they imitate. Other ingredients such as tablet fillers, binders, coatings or flavors may differ. Because their development costs are less, generic drugs are often priced substantially lower.

When you receive a prescription from your doctor, ask if a generic equivalent is available. Many health plans charge a lower copay for patients who choose generics.

Here is a look at some of the major health care reform provisions that you will see over the next decade.

2010

Employers: Small businesses can receive tax credits if purchasing insurance for employees.

Insurers: Cannot impose pre-existing condition exclusions on coverage for children. Must cover preventive services without copays. Cannot remove coverage when a person becomes ill. Cannot impose lifetime coverage limits.

Uninsured: Individuals with pre-existing conditions receive immediate access to coverage through a high-risk pool. Dependent children can remain on parents’ plans until age 26.

Early retirees: Employers will be able to participate in a reinsurance program to help provide coverage for retirees and their spouses, surviving spouses and dependents over age 55 and not eligible for Medicare.

Medicare Part D enrollees: A $250 rebate check received for those entering the “doughnut hole” gap in coverage in 2010. Rebate payable by April 1, 2011.

2011

Insurers: Required to spend at least 80 percent of premiums on medical services.

Medicare Part D enrollees: Receive a 50 percent discount on brand-name prescription drugs when in doughnut hole coverage gap.

Those with health care savings accounts: Federal tax on those who spend health care savings account money on ineligible medical expenses increases to 20 percent.

Over-the-counter drugs: Except for insulin, OTC drugs without a prescription are not reimbursable from an FSA or HRA, and are not a tax-free reimbursement from an HSA.

W-2: The value of your health coverage must be disclosed on your W-2 form (optional for 2011).

2012-2013

Taxpayers: Medicare payroll taxes increase to 2.35 percent for individuals earning more than $200,000 and families earning more than $250,000.
Those with flexible savings accounts: A federal limit of $2,500 for individual pretax contributions per year.

2014

Employers: Companies with 50 or more employees must provide affordable coverage or pay a penalty.

Insurers: Prohibited from refusing to sell or renew policies. Cannot deny coverage for adults with pre-existing conditions. Limits ability to set prices on the basis of sex, health status or other factors. Prohibited from imposing annual limits.

Uninsured: Most Americans required to buy health insurance or pay fines of $95 per individual and up to $285 per family. Families will pay half the amount for children. Families can receive subsidies to buy insurance if they earn no greater than four times the federal poverty level (about $88,000 per year for a family of four). Individuals and small businesses can buy packages through state exchanges.

2015

Uninsured: Penalties for not carrying insurance increase to $325 per individual and up to $975 per family. Families will pay half the amount for children.

2016

Uninsured: Penalties for not carrying insurance increase to $695 per individual and up to $2,250 per family or 2.5 percent of taxable family income – whichever is greater. Families will pay half the amount for children.

2018

Taxpayers: A 40 percent excise tax imposed on high-cost employer-provided policies ($10,200 for individual coverage or $27,500 for family coverage).

2020

Medicare Part D Enrollees: Prescription drug coverage gap eliminated.

Good Posture

The Cleveland Clinic Department of Patient Education and Health Information defines posture as the position when one holds his/her body upright against gravity. Good posture involves training the body to stand, walk, sit and lie in ways to place the least amount of strain on muscles and ligaments.

There are many physical benefits to having good posture, such as:

• Keeping your bones and joints in the correct alignment to ensure that muscles work properly
• Decreasing abnormal wear on joint surfaces (may result in arthritis)
• Decreasing the stress on ligaments which hold the spine together
• Preventing the spine from fixing in an abnormal position
• Lessening fatigue
• Preventing strains, backaches and muscular pain

Contributions to Bad Posture

Though it is not a conscious decision most of the time, many workers have bad posture which can result in injuries. Here are some common behaviors that contribute to bad posture:

• Shoulders hunched forward while slouching
• Forming a “swayback” (also known as lordosis) in which there is an inward curve in the lower back
• Carrying a heavy load on one side of the body
• Cradling a phone receiver between the neck and shoulder
• Wearing high-heeled shoes without arch support or clothes that are too tight
• Excessively looking up or down
• Slumping or sliding in a forward position in a desk chair

Helpful Solutions

Want to ease strains and prevent back and neck injuries? Here are some recommendations for standing, sitting and lying down:

Standing Properly:

• Put your chin in and keep your head up
• Keep your earlobes in line with the middle of your shoulders
• Keep shoulder blades back and chest forward
• Keep your knees straight and tuck in your stomach
• Extend your head towards the ceiling

Sitting Properly:

• Place your shoulders back and your back straight
• Evenly distribute your body weight on both hips
• Bend your knees at a right angle and keep your feet rested flat on the floor
• Adjust chair height to sit close to your workstation
• Do not twist at the waist to grab something, turn your entire body
• Avoid sitting in the same position for more than 30 minutes

Lying Down Properly:

• Lie in such a way to maintain the curve in your back such as on your back with a pillow under your knees
• Place a lumbar pillow under your lower back or on your side with the knees bent
• Sleep on a firm mattress with a box spring that does not sag

Pick a Loved One

Many people wait until there is an emergency before they go for a
checkup, but regular health care visits and screenings are essential for preventive care and improved quality of life. Any day is a great day to take a loved one in for a checkup. Identify someone you know who hasn’t

been to health professional lately and offer to make an appointment and take him or her to the doctor. Or, if you haven’t been to see a doctor in a while, make an appointment for yourself.

When your loved ones are connected with the right medical care, they can find out about their health concerns. Many health problems can be treated when detected early, or prevented all together. It is also an opportunity for patients to get specialty referrals if necessary for follow-up care.

Pick a Place

Events such as health fairs and screenings are often planned by local organizations. Often, community health forums and local media -promote such events and programs. Some are even nationwide, such as the Take a Loved One for a Check Up Day or Take a Loved One to the Doctor Day.

Local community-based organizations, including health centers and health departments often participate as well, providing transportation and appointments for patients. Local civic groups, businesses and other organizations can participate in these types of efforts, which provide an opportunity to increase access to health care and early detection of chronic conditions like diabetes, heart disease, stroke, cancer, infant mortality, child and adult immunization, and HIV/AIDS.

Other Resources

If you or your loved one do not already have a doctor, or do not have health insurance, then contact your local community health center or local health department to ask about free or low-cost care. Then, follow through and make an appointment!

One out of every two women and one in four men over the age of 50 will break a bone in their lifetime because of osteoporosis. Calcium helps to keep your bones strong and less likely to break. Adults ages 19 to 50 need at least 1,000 mg of calcium daily. To get more calcium into your diet, try the following:

• Eat foods with calcium, such as fat-free or low-fat milk and yogurt, spinach and greens, tofu made with calcium, and orange juice with added calcium.
• Take a calcium pill daily (talk to your doctor before choosing this option).
• Check the label on the foods you buy: the best choices are items that have at least 20 percent DV of calcium.
• Make sure you’re getting vitamin D, which aids in calcium absorption. You can get vitamin D in salmon, milk, some yogurts, and vitamin D pills.

There are no signs or symptoms of osteoporosis; in fact, you may not know you have it until you break a bone. This is why getting enough calcium is so important. If you are 65 or older, you should get a test to find out your bone strength (called a bone density test).

You may be at a higher risk for osteoporosis if you:

• Have a small, thin body size
• Have an eating disorder (or are recovering from one)
• Have a family history of the disease
• Do not exercise regularly
• Have low estrogen levels (women) or low testosterone levels (men)

Health Benefits of Laughter

Laughter makes you feel better in the moment, and also has long-term benefits:

• It reduces stress hormones in the body by releasing endorphins in the brain.
• It can lower blood pressure.
• It improves alertness, creativity and memory.
• Laughter increases the intake of oxygen while also stimulating the heart, lungs and blood vessels.
• It improves the immune system.
• It helps the body produce natural painkillers.
• Laughing helps you get through tough situations and enables the body and mind to relax.

Give Yourself a Dose of Laughter

It’s easy to incorporate some healthy laughter into your day. Consider these ideas:

• Hang up silly pictures of your family and friends, comic strips or jokes around your home and office.
• Look for the silver lining or comical aspects of everyday struggles. Associate yourself with others who try and do the same, rather than those who tend to focus on the negative.
• Whenever you feel overwhelmed or negative, watch a funny movie or television show, or play with your children or pet.
• Buy a joke book or find an author whose writing you find humorous.
• Host a game night with family and friends.
• Listen to a comedy CD on your commute to and from work.
• Do not take yourself too seriously; know when you need to relax.

You know what they say… laughter is contagious. So, spread some around to benefit your health and the health of those around you!

How you will be affected by the recently passed health care reform legislation varies greatly depending on your age, who you work for and many other factors. So what does it mean for you? Below are common categories that many Americans fall under, and how reform will affect their coverage.

Elderly: Effective this year, the elderly will receive free preventive services under Medicare – to be expanded to wellness visits and personalized prevention plan services in 2011. Also effective in 2010, those with Medicare prescription drug coverage will receive a $250 rebate once the “doughnut hole” coverage gap is met. Medicare beneficiaries earning $85,000 or more will pay higher Part B premiums until 2019. Those with Medicare Advantage plans may lose some benefits or experience an increase in copayments.

Employees of a large company: Employers with 50 or more employees will be required to provide coverage or pay a penalty starting in 2014. Existing coverage packages will be grandfathered in, but new plans will have to meet minimum requirements. Caps on out-of-pocket spending will take effect and are intended to keep costs down. Despite this, premiums could continue to rise, and those who do not qualify for subsidies or exchanges may have no choice but to opt for employer-sponsored plan.

Low-income employees: Even without children or a disability, those among the lowest-income workers will be eligible for Medicaid as of 2014. Those who earn less than 400 percent of the federal poverty level (about $88,000 for a family of four) will be eligible for subsidies to help buy coverage. The expansion of funding for community health centers, designed to offer free and reduced-cost care, will also provide relief. Despite these options, getting coverage could still strain a low-income budget unless qualified for an exemption.

Children with a pre-existing condition: Group health plans and health insurance issuers may not impose pre-existing condition exclusions on coverage for children effective this year. Provision applies to all employer plans and new plans in the individual market.

Adults with a pre-existing condition: Starting 2014, when buying individual coverage, obtain it through the insurance exchange and pay the same as others in same age group. Insurers cannot place annual or lifetime limits on coverage, nor can they deny coverage or charge higher premiums due to a pre-existing condition.

Unemployed and uninsured: Most likely will qualify for Medicaid under coverage expansion starting 2010. The expansion of funding for community health centers, designed to offer free and reduced-cost care, will also provide relief. Certain uninsured individuals with pre-existing conditions can obtain coverage through the temporary high-risk pool effective this year as well.

Small-business owners: Effective 2010, those with 25 or fewer workers may be eligible for a tax credit to help provide coverage for employees. Those with 50 or more employees must provide benefits or incur a penalty starting in 2014. Small-business owners will be able to buy insurance for employees through insurance marketplaces by 2017.

Young adults: Those who are 26 or younger may stay on parents’ policy effective 2010. Those who buy coverage on their own or through the exchanges can obtain cheaper catastrophic coverage. Those who obtain traditional benefits packages will pay less than those who are older, but can be pricier than what is available now. Must obtain coverage unless qualified for an exemption starting 2014.

If you know the number of your total cholesterol, that’s good. But is it good enough?

What’s in a Number

In the past, doctors thought that total cholesterol was a good indicator of one’s risk for heart disease, heart attack, diabetes and stroke. The lower your low-density lipoprotein (LDL) numbers and the higher your high-density lipoprotein (HDL) numbers, the better, right? While measuring HDL, LDL and total cholesterol is helpful, experts now know that to truly assess your risk for heart attack, heart disease and stroke, it’s not as simple as just knowing these numbers.

The Lipoprotein Link

Research indicates that no matter how much cholesterol you inherit or take in when you eat, the blockage of arteries that leads to heart disease is caused by the number and size of the lipoprotein particles that carry cholesterol throughout your body. These lipoprotein particles can build up in your arteries. Think of it this way: These lipoproteins are the cars that carry passengers (cholesterol) along the highway – it’s not the number of “passengers” in a car that causes a traffic jam (blocked artery), it’s the number of cars!

Your Particle Number

The number and particle size of lipoproteins in your blood are the measurements than can really help your doctor determine your risk for heart attack, heart disease and stroke. A screening test called an NMR LipoProfile® is available, which provides a more detailed look at how your particles measure up. The number of LDL particles circulating in your blood is the most important factor in measuring your heart health. It is important to know how many there are and how big they are. Generally, the lower your number of total LDL particles, and the larger the size of these particles, the lower your risk is for heart disease, heart attack and stroke.

Getting Tested

Currently, most patients and many doctors are not even aware that a simple blood test exists than can analyze your cholesterol numbers in such detail. Those who do, however, realize that it is a valuable tool necessary for early prediction, prevention and treatment of heart attack, heart disease and stroke. If you have a family history or other risk factors for heart attack, heart disease and stroke, or have already been diagnosed with high cholesterol (even if you are already being treated for it), ask your doctor about having an NMR LipoProfile test. It is currently covered by many private insurance carriers, although different rates and coverage do apply. If your insurance doesn’t cover it, consider having it done anyway. The test is relatively inexpensive, and the results you get are important for your health.

Tired of waiting to get into the doctor’s office? There are new trends emerging which are more affordable and accessible for patients.

In many states, clinics are arriving inside the CVS, Rite-Aid, Walgreens, Duane Reed, Osco Drug, Wal-Mart and Target stores. These clinics focus on the convenience of fitting into a consumer’s daily schedule. It is now possible to take care of errands, get a sinus infection diagnosed (with about a 15-minute wait for a walk-in), and fill the prescription all in one stop. This is a welcome relief for those accustomed to hassles such as being squeezed into a doctor’s schedule, getting to the doctor’s office, and dealing with the inevitable wait in the waiting room.

These new clinics keep regular retail hours, and an office visit costs less than in most physician offices. One of the clinic companies, MinuteClinics, reports that a visit to one of their clinics tends to cost between $40 and $60 for most ailments, compared to upwards of $150 for a typical physician’s office. These clinics do take insurance, but are also very cognizant that many of their patients are paying out of pocket or with an HSA. They make it work by only treating certain ailments. This strategy also underscores that these clinics are not intended as a replacement for a primary care physician; they just offer a very convenient and cost-effective supplement to his or her service.

In the West Coast, Clinica Mi Pueblo in Anaheim, California, is leading a trend for cash-only clinics targeted at Spanish speakers. These clinics stay open until midnight seven days a week and charge $25 for an office visit (compared to $77 to $104 at area physician offices). They even offer coupons for 10 percent off. Storefront clinics like this have popped up rapidly in response to a strong consumer need for accessible and reasonably-priced health care. Costs stay low because the clinics avoid the administrative hassle of insurance paperwork altogether; they just don’t accept it.

In such cases as Clinica Mi Pueblo, there is also a cultural component. These clinics have bilingual staff, which makes a tremendous difference for Spanish-speaking people in need of health care. For example, if a doctor advises a patient against fatty foods, he or she can refer to certain Latin dishes by name.

One caveat critics have noted is that it’s not always possible to count on the standard of care received at a storefront clinic, especially when compared to the non-profit community clinics that have long tried to fill this service gap for America’s uninsured. The non-profit community clinics generally receive some federal funding along the way, which means they have to be up to federal standards. The more entrepreneurial storefront clinics do not. But that doesn’t change the fact that cash-based medical care for the modern American is in the process of evolving to meet time and convenience needs.

The administrator for RediClinics, Web Golinkin, puts it this way: “I think that, in the broadest sense, health care is becoming more consumer-driven for a whole variety of reasons. Consumers are being asked to pay more of their health care directly out of pocket. In some cases, it is coming out of health savings accounts, and in some cases, employers have raised deductibles and copays. So, consumers both want and need to take more control of their own health care, and they’re doing that.” As consumers cast their collective vote, it’s entirely possible to see more market adaptations like these new clinic models.

Are you sold on the benefits of wellness, but having trouble fitting it into your budget? There are plenty of low-cost wellness strategies and ideas that can help improve the health of your workforce.

Nutrition

• Provide healthy eating reminders and education using posters, email, payroll stuffers, etc.
• Offer healthy food and beverages in vending machines, office meetings and parties, cafeteria, etc.
• Make kitchen equipment available to employees.
• Provide an on-site garden, if possible.

Physical Activity

• Host walk-and-talk meetings.
• Offer flexible work hours to allow for exercise during the day.
• Offer on-site fitness opportunities, such as classes, walking trails, exercise equipment, etc. Provide changing and showering facilities, if possible.
• Provide motivational and educational signs, newsletters, flyers and emails.
• Start employee walking clubs, fitness challenges, sports teams or other groups.
• Offer safely and conveniently located bicycle racks.

General Health

• Develop policies that support wellness initiatives, such as prohibiting tobacco use on company property.
• Promote and encourage employee participation in wellness activities.
• Host an annual health fair.
• Provide regular health and wellness education for employees, in the form of flyers, emails, posters, presentations, seminars, etc.

• Make your health plan more wellness-oriented, such as providing weight management counseling, tobacco cessation treatment and other wellness services at no cost.
• Encourage employees to get recommended preventive screenings and immunizations, and emphasize that they are cost-free under your plan.