Although health plans and other entities may have primary responsibility to inform patient-members about plan provisions that will affect the availability of care, physicians share in this responsibility.
Individually, physicians should:
- Disclose any financial and other factors that could affect the patient’s care.
- Disclose relevant treatment alternatives, including those that may not be covered under the patient’s health plan.
- Encourage patients to be aware of the provisions of their health plan.
Collectively, physicians should advocate that health plans with which they contract disclose to patient-members:
- Plan provisions that limit care, such as formularies or constraints on referrals.
- Plan provisions for obtaining desired care that would otherwise not be provided, such as provision for off-formulary prescribing.
- Plan relationships with pharmacy benefit management organizations and other commercial entities that have an interest in physicians’ treatment recommendations.