How Can Insurance Dictate Your Medication?

A common feature of all insurance plans whether it’s Medicare, a group or an individual policy is to regulate the prescription drugs prescribed for its members. This is done in four ways: requiring a prior authorization, step therapy, maximum dispensing limits or excluding certain medications from its prescription drug list.

Prior Authorization

Some drugs must undergo a criteria-based approval process by your insurance carrier prior to being covered under your health insurance plan. The approval process varies by insurance provider.

Step Therapy

Step therapy protocols require you to utilize medications commonly considered first-line medications prior to being able to using a medication considered second line or third line. You receive benefits for drugs subject to step therapy only after trying alternative medications first.

Prescription Drug List (PDL)

Your insurance carrier creates a prescription drug list (PDL) each year which dictates which medications are or are not covered by your insurance plan. The list can also change during the year depending on your policy guidelines.

Maximum Dispensing Limits

Maximum dispensing limits are based on the product information approved by the Federal Drug Administration (FDA) and recommendations from the drug’s manufacturer. Your carrier limits the quantity of medication you are able to receive from your pharmacy at one time.


According to Humana, a health insurance company, the cost of a drug drops in price between 30 percent to 80 percent once the patent expires and it is available as in a generic form. Step therapy, prior authorization and PDL are ways to help control health care costs with maximum dispensing limits in place as a safety measure.


You may not like the measures implemented by your insurance company to restrict dispensing specific medications; you can however get an exception made to each of the restrictions. The procedure for doing this will vary depending on your insurance carrier.

Group Medical Insurance Keeps Employees Happy and Improves Business

Businesses struggling in the current economic climate are seeking new ways to improve the bottom line, and group medical insurance is proving to be a beneficial tool for creating better business. From tax incentives to employee retention, offering group health insurance to employees can provide a win-win situation for both employer and employee.

Also known as an employer-sponsored health plan, group medical insurance is on the chopping block for many businesses that are trying to cut costs and keep their companies afloat. Because most Americans receives family health insurance coverage through an employer-sponsored group plan, the elimination of these health plans could result in major financial struggles for working Americans.

However, business owners who chose to keep a group medical insurance plan as part of their employee benefits package are discovering that it improves not only employee moral but also the bottom line. They are more likely to attract the best workers and are able to decrease employee turnover rates. As for improving business finances, group medical insurance plans pave the way for tax incentives.

Business owners who contribute to employee premiums or share costs with employees, can typically deduct 100% of premiums paid. In addition, it is possible to reduce payroll taxes when the medical insurance coverage is part of a total compensation package.

Having quality employees is vital to a good business, and providing group medical insurance is vital to obtaining and maintaining quality employees. Even if the business budget is tight, it is still possible to find an affordable medical insurance package that keeps employees happy, protected and performing well to benefit your business.

As an employer, you select a group health insurance plan and invite your employees to enroll. Typically, employers cover at least 50% of each employee’s monthly premium, and can also contribute to dependent premiums. The remainder is paid for by the employee. If you want to provide health insurance benefits and you’re able to contribute toward employee premiums, group health insurance is the way to go.

Compare all of the plans that are available to you before making your decision on which plan to go with. All of the top insurance companies in your area should offer you a good selection of plans. To compare plans from different insurance companies visit a website that can offer side-by-side comparisons and plan price quotes. Be sure to check that sites rating with a service such as the Better Business Bureau.

When You Find Out Your Employee’s Medical Leave of Absence Was Really Spent at Disneyland

Dishonest workplace absences are nothing new. In fact, over 30 per cent of employees have called in sick when they’re not actually sick, according to a national CareerBuilder survey of more than 3,400 workers across varying industries and company sizes.

Outside of one-to-two day medical leaves, what can employer’s do when faced with a long term medical leave of absence that might be fraudulent?

Back to Bob Smith, for example. There’s no debating that Diane Jones does have a new Disney coffee mug sitting on her desk. But how should the employer handle the situation?

Before accusing Bob of ditching work for the theme park, first verify what is correct and current:

  • Is it possible Bob ordered the gifts on line?
  • Is it possible the gifts had been sitting in Bob’s closet since his last vacation?
  • Were the gifts really even from Bob? Is there nefarious intent on the co-workers part in revealing this recent ‘gift’ information?

Unfortunately, most employers don’t have the time or the resources to enact detective-like investigations when determining the legitimacy of absences. The key in these medical leaves is to look at the surrounding circumstances to determine if the illness really does exist instead of simply taking the employees word for it.


The easiest way to begin controlling absenteeism is by review of your current policy manual. What wording do you have in place that addresses attendance? Do you have anything written at all? Some companies require employee’s to call a call-off line when reporting an absence; others require a physician’s statement of return-to-work if absent for three or more days. Still other practice an intensive up front Q&A with the absent employee: [Will they see a doctor for their illness? What duties of the job can they not perform? The specific reasons for the absence? When do they anticipate returning to work? Etc.]. Is there content available within your policy that clearly defines what is considered excessive absenteeism?

Employers who mark their line in the sand up front with new employees often have a less difficult time later in the employee’s tenure. Establishing, promoting and enforcing policy with all employee’s, however, may make a drastic impact on overall daily attendance.

But what of the extended medical leaves of absence? Those leaves that continue beyond one or two days? Are those employee’s automatically eligible for FMLA?


FMLA requires covered employers to provide up to 12 weeks of unpaid, job-protected leave to eligible employees for the following reasons:

• Incapacity due to pregnancy, prenatal medical care or child birth;

• To care for the employee’s child after birth, or placement for adoptions or foster care;

• To care for the employee’s spouse, son or daughter, or parent, who has a serious health condition; or

• For a serious health conditions that makes the employee unable to perform the employee’s job.

The Family Medical Leave Act was enacted to protect workers who might otherwise be terminated as an indirect (or direct) result of serious medical or pregnancy/child-related issues.

But are these leaves enforceable? What rights do employers have to ensure extended medical leaves covered by FMLA are legitimate? Before you throw in the towel and start giving Bob your Disney wish list, consider the following:

1. You can ask for medical certification. This means your employee must submit documentation from a certified medical professional. There are certification forms available for both an Employee’s Serious Health Condition and a Family Member’s Serious health Condition [both forms can be found HERE ]. Make sure to include the employee’s job description when submitting these forms to the physician.

2. You may seek additional clarification by your own physician.

3. You may establish an enforceable and reasonable recertification – which means the employee has to perform Step 1 as many times as the recertification applies.

4. You may require a personal certification. This means the employee acknowledges the reasons he or she is taking a FMLA-related medical leave. If it is determined that a person has taken leave that is inconsistent with his or her personal certification this could be grounds for discipline.

As with all policy, enforcement should be fair and equal. Don’t give one employee all of the paperwork and another employee only a few forms. Keep all FMLA documentation in a separate FMLA folder in your medical drawer. If you do elect to keep FMLA certification forms in an employee’s medical folder make sure it is clearly identifiable as certified FMLA paperwork.

While most extended medial leaves are legitimate and necessary, fraudulent misuse of these leaves and FMLA abuse are “popular” enough to warrant several forum discussions and employer confusion and frustration.

Avoid misguided attempts at discipline until you have all the facts, documentation, and an air-tight case of fraudulent abuse. Even then, proceed with caution.

*All names in this article are fictitious. This article should not be construed as legal advice. If you think an employee is misusing a medical leave of absence or abusing FMLA, contact a FMLA attorney to discuss your options and employer rights.