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Deb Gordon

Deborah D. Gordon has spent her career trying to level the playing field for healthcare consumers. She is co-founder of Umbra Health Advocacy, a marketplace for patient advocacy services, and co-director of the Alliance of Professional Health Advocates, the premiere membership organization for independent advocates. She is the author of "The Health Care Consumer's Manifesto: How to Get the Most for Your Money," based on consumer research she conducted as a senior fellow in the Harvard Kennedy School's Mossavar-Rahmani Center for Business and Government. Deb previously spent more than two decades in healthcare leadership roles, including chief marketing officer for a Massachusetts health plan and CEO of a health technology company. Deb is an Aspen Institute Health Innovators Fellow, an Eisenhower Fellow and a Boston Business Journal 40-under-40 honoree. Her contributions have appeared in JAMA Network Open, the Harvard Business Review blog, USA Today, RealClear Politics, The Hill and Managed Care Magazine. She earned a BA in bioethics from Brown University and an MBA with distinction from Harvard Business School.

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Health Insurance 101: How to Choose Health Insurance if You Have Asthma

7 questions to explore when you’re evaluating health insurance options for asthma care

Your Care

If you have asthma, choosing the right health insurance can help you get the treatments you need with less hassle.

Asthma treatments fall into two main categories:

  1. Long-term medicines to control asthma, often taken every day
  2. Medicines that give short-term relief from asthma symptoms, sometimes called “rescue medications”

For people with allergies that trigger their asthma symptoms, allergy medicines can also help.

Common medicines, such as corticosteroids, reduce inflammation in the airways. Newer drugs called “biologics” are made with cells from living organisms and interfere with inflammation in the first place.

Read: You Don’t Have to Live With Uncontrolled Asthma >>

Depending on your insurance coverage, the drugs you need can be easier (and cheaper) or harder (and more expensive) to get. Make sure you understand what asthma care your health insurance covers.

Whether you get your health insurance through a job or a government program, here’s what to look for when you’re choosing a plan.

1. Does the provider network include a range of asthma specialists?

Check the plan’s provider directory to make sure your healthcare providers (HCPs) participate in the health plan’s network. Even if you don’t see an asthma specialist today, you might need to in the future. Make sure the plan offers a range of specialists available.

2. Are the asthma drugs you need covered?

It may seem like a simple question, but whether your health insurance covers a specific medication can be complicated to answer. The first step is to check the preferred drug list (PDL) or “formulary,” the list of drugs that your health plan covers.

If the drug is on that list, that’s not the end of the story. Even covered medicines can be subject to rules such as prior authorization. That means you may have to get permission from your health plan before they’ll pay for the drug. If they deny your request, you can appeal. You might win, but there’s no guarantee.

Read: What You Need to Know About Prior Authorization >>

3. How do health plans decide which medications are covered?

Most health plans pay a separate company to manage their drug benefits. Those companies are called pharmacy benefit managers (PBMs). PBMs decide which drugs go on the PDL. Coverage decisions may be based on data about cost, effectiveness, available alternatives (if any), and generally accepted treatment guidelines.

PBMs also negotiate drug prices with drug makers and pharmacies, decide what patient copayments or other costs should apply, and set rules for access to specific drugs. PBMs sometimes manage specialty or mail-order pharmacies that health plan members are encouraged (or forced) to use.

Read: Pharmacy Benefit Managers Are the Most Influential Healthcare Companies You’ve Never Heard Of >>

4. What is the process for getting coverage for your medicine?

If your health plan requires prior authorization for your medicine, you’ll have to get their permission before they’ll pay for it. The process to get that permission can be confusing. Usually, the HCP who prescribed the medicine will help. They’ll need to fill out a form and explain their reasoning for prescribing that medication for you. The health plan may follow up with the HCP for more information.

If the health plan denies your request, you usually have the right to appeal. The plan has to give you information about how to file an appeal. Again, your HCP or their office may help. The appeal may include more details from you and/or your HCP about why the medicine is necessary for you. Your HCP may need to show how the treatment fits within standard treatment guidelines, or why you need something different.

Sometimes you have the right to more than one level of appeal. You may be entitled to ask an external reviewer to look at your health plan’s decision and consider overturning it.

Plan-specific and state rules vary. Check your member handbook or ask the health plan customer service for step-by-step instructions for submitting a prior authorization request, and if necessary, an appeal. Your state’s insurance commission may help if you get stuck.

5. If your medicines are covered, how much will they cost you?

For covered medicines, you usually have to pay a copayment, a set fee every time you fill a prescription. The amount of that copayment can depend. For example, there are usually different copayments or other costs for drugs depending on how the plan categorizes them, called “tiers.” Tier 1 drugs might have the lowest copayments and fewest restrictions. Higher-tier drugs may cost you more and may come with more rules or hurdles.

Specific drugs may also be considered “preferred” or “non-preferred,” which may influence how much the drug costs you and how easy it is to get. The PDL should include these designations, if applicable.

In addition to copayments, other factors can affect your costs. If you have a deductible, you’ll have to pay the full drug cost until you meet the deductible.

Your health plan may also have a cap on the total you pay out of pocket each year, called an “out-of-pocket maximum.” If you reach that cap, you won’t have to pay any more copayments. But check the details — these caps may not kick in until you’ve paid many thousands of dollars.

6. What’s the policy on covering new treatments as they become available?

When you’re looking at health insurance options, check the policy for covering new treatments when they become available. You can’t know for sure what future drugs your health plan will cover, but you can at least read their policy about how they decide which ones to cover. Ask the customer service team for that policy if you can’t find it easily.

You can also search health plan ratings to see how other people rate the plan, specifically on how easy it is to access needed care. Though it won’t predict what your specific experience will be, it can give you a sense of how other people feel about the plan’s coverage policies.

7. What is a specialty pharmacy?

Some medicines aren’t available through a typical retail or mail-order pharmacy. Medicines that aren’t used very often, need special handling, get injected or infused, or require special follow-up may only be available from a specialty pharmacy.

Specialty drugs may be more restricted and costly. You may have to follow specific rules or procedures to get them. Some asthma medications fall into this category.

Read your health plan documents for information about how to get specialty drugs if you need them. Your insurer may require you to use their preferred specialty pharmacy.



This educational resource was created with support from Amgen, a HealthyWomen Corporate Advisory Council member.

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C. diff is the name of a common, easily transmittable infection caused by the bacterium Clostridioides difficile. The infection causes your colon (bowel) wall to become inflamed, resulting in severe, watery diarrhea. Left untreated, it can cause a serious complication called toxic megacolon.

C. diff affects about 250,000 people in the United States every year. Some people get it only once in their lifetime, but if you have a C. diff infection, there is up to a 1 in 4 chance you might relapse (the same infection returns) or get it again within eight weeks. People at the highest risk for a C. diff infection are those who take or have recently taken antibiotics, especially if they have a weak immune system.

The bacteria live in feces (poop), and in soil and water. They spread easily and can live for a long time on hard and soft surfaces, like linens and clothing. If someone who has C. diff on their hands touches a door handle and you touch it after, the bacteria transfer to your hand. They then can enter your gastrointestinal system if you touch your mouth or handle food before washing your hands.

Protect yourself and others from getting a C. diff infection in a healthcare setting

hand washing in a hospital

If you are a patient in a hospital, skilled nursing facility or rehabilitation center, you are at higher risk of getting a C. diff infection — not just because you likely have a weak immune system from the condition that put you in the facility but also because of the number of people you may encounter while you’re there.

Here are some steps you can take to lower the risk of getting C. diff in a healthcare facility:

  1. Make sure all healthcare workers and visitors wash their hands before they touch you and your things. If you don’t see them wash their hands, ask them to do so.
  2. Wash your hands well with soap and water every time you use the bathroom. If you use a bedside commode, ask to be transported to a sink to wash your hands or use a waterless hand sanitizer.
  3. Wash your hands before eating or drinking. If you can’t get to a sink, ask the staff or a friend to supply you with a waterless hand sanitizer to use while you are in bed or sitting in your chair.
  4. Allow cleaning staff access to your environment. Clear everything off the bedside table or nightstand, and remove clothing or linens from the bedside rails so they can be wiped down.

Patients with a diagnosed C. diff infection should not share a room with someone who does not have the infection. If you do share a room and your roommate contracts C. diff, ask to be moved.

Stop the spread of C. diff at home

household cleaning supplies

C. diff doesn’t just affect people in healthcare facilities. It can happen at home, too.

Here are steps you can take to reduce the risk of spreading C. diff at home:

  1. If your home has a second bathroom, reserve one for the person with the C. diff infection to limit exposure to others.
  2. If your home has only one bathroom, make sure the toilet seat, flusher, faucets, light switches and doorknob are cleaned with a bleach-based cleaner after each use.
  3. If the infected person is immobile, keep waterless hand sanitizer within reach.
  4. Clean common home surfaces (door knobs, light switches, fridge handles, etc.).
  5. Wash clothing (especially underwear), towels and linens separately and in the hottest water possible.
  6. Wear disposable gloves while handling clothing and linens, especially if the person is incontinent (loses control of their bowels). Wash your hands after removing the gloves.
  7. Shower with soap to remove C. diff that may be on the skin.

This educational resource was created with support from Seres Therapeutics and Nestle Health Science.