Drug Insurance Coverage Flashcards
Commercial Insurance
private employer-sponsored insurance
Medicare Part D
Covers prescription drugs for seniors & disabled individuals
Medicaid & Managed Care Plans
Covers low-income individuals
Employer-Sponsored Insurance (ESI)
Covers 50%+ of americans
Managed Care Organizations (MCOs)
Private insurers managing Medicaid/Medicare Advantage
State-Specific Programs
EPIC
Child Health Plus
Essential Plan
Pharmacy Benefit Managers (PBMs)
Manage prescription drug claims
Intermediaries b/w insurance companies, pharmacies, + manufacturers
Negotiate pricing & rebates
Formularies
Process claims for insurers
Parent company of CVS Caremark
CVS Health
Parent company of Express Scripts
Cigna
Parent company of OptumRx
UnitedHealth Group
Parent company of Prime Therapeutics
BCBS Plans
Parent company of MedImpact
Independent PBM
How PBMs pay pharmacies
Ingredient Cost
Dispensing Fee
DIR Fees (no longer allowed)
Issues affecting reimbursement
DIR Fees
Below-Cost on generic meds
Spread Pricing
Preferred networks=larger chains
Slow processing
PBMs deduct DIR fees ______ after claim is processed
weeks or months
DIR fees can range from ______ of drug cost
2-9%
PBMs set _______ pricing, which does not often reflect market costs
Maximum Allowable Cost (MAC)
MAC Appeals
Pharmacies can file appeals if they believe reimbursement is too low
Spread pricing
PBMs charge insurers more than they pay pharmacies and keep the difference
PBMs steer patients to _____ or _____ pharmacies.
mail-order
PBM-owned
Strategies to improve reimbursement
monitor DIR fees and MAC
negotiate better contracts
legislative changes
educate patients on cash/GoodRx
Key Fields on Insurance Card
RxBIN
RxPCN
RxGroup
Member ID
Prior Auth Required
Use CoverMyMeds or call prescriber to submit PA
Plan Limits Exceeded
Adjust quantity/days or request override
