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Friday, January 8, 1999 - Page updated at 12:00 AM

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State Wants Insurers To Provide Details On Prescription Coverage

Seattle Times Staff Reporter

The state is investigating a complaint from a consumer with a life-threatening illness who says her insurance carrier stopped paying for her drugs in mid-treatment with little notice.

Insurance Commissioner Deborah Senn did not disclose details of the complaint but cited it as an example of why consumers need more information on the prescription coverage their health plans provide.

Yesterday Senn filed proposed rules for health plans on what insurance carriers would be required to disclose up front to consumers. A public hearing on the proposal is set for Feb. 23. The rules could become effective in mid-March.

Senn is seeking comments from consumers and the insurance, health-care and pharmaceutical industries on about 10 recommended disclosures.

Among them, Senn has proposed that health-insurance carriers provide the following information to consumers:

-- Whether the plan limits or excludes certain drugs that may be prescribed by a doctor, and whether substitutions will be encouraged for some drugs.

-- When the plan can change the approved drug list or formulary.

-- If a change occurs, whether the consumer will have to pay more or could be "grandfathered" to continue with a drug already in use.

-- What phone number consumers can call to request a change in coverage or make an appeal.

-- What consumers must pay to get a prescription filled.

-- Whether their plan requires consumers to use specific pharmacies, and their locations, to pay the least out-of-pocket expenses.

-- How many days of medication a consumer gets per co-payment.

Senn's staff and industry representatives were involved in a year-long task force that studied consumers' complaints about prescription and mental-health benefits.

Representatives of Premera Blue Cross and Regence Blue Shield were part of the task force and said it was a positive, collaborative approach.

But while Premera wants to support the disclosure recommendations, officials at the insurer said, they're concerned about the cost of providing information on dozens of prescription plans and whether that detailed information might confuse consumers.

Regence already provides most of the information, said spokesman Chris Bruzzo.

"We are in strong agreement with the commissioner that more information, and direct, clear communications can go a long way to avoid confusion and mixed expectations," Bruzzo said.

Regarding mental-health treatments, Senn's proposal also would require insurance carriers to tell consumers what information about them would be disclosed to entities other than medical providers, how many mental-health visits the plan covers and how that coverage can be used.

For more information, see the insurance commissioner's Web site at http://www.wa.gov/ins or call the agency at 800-562-6900.

Copyright (c) 1999 Seattle Times Company, All Rights Reserved.

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