Payment Methods for Prescriptions

Question 1

Third party billing

Answer 1

Financial coverage for medications/pharmaceutical aids involving a contractual agreement between a third party payer and the pharmacy

Question 2

Formulary

Answer 2

List of medications approved by the insurance company as an eligible benefit
Alberta Blue Cross sets formulary standard, work with government for certain populations and also have private plans

Question 3

Copay

Answer 3

Portion of prescription price that patient pays (may include a percentage or cost of prescription above what the plan pays)
% of copay is variable

Question 4

Deductible

Answer 4

The amount patient pays every year before insurance company starts paying its share of the costs
E.g., if the deductible is $1000, the patient pays cash for first $1000 in medication each year, after which insurance company pays its share
Patient essentially needs to buy into the plan to get the benefits

Question 5

Out-of-pocket limit

Answer 5

The most cost-sharing a patient will have to pay in a year. Total of deductibles, copays, and co-insurance (but does not include premiums). Once a patient hits the limit, the insurance company will pay 100% of costs for the rest of the year

Question 6

Manufacturer List Price

Answer 6

The price for a drug listed by the Alberta Drug Benefit List (ADBL) which is determined by Alberta Health and the pharmaceutical manufacturer

Question 7

Base price

Answer 7

Price per unit of a drug, a drug product, or a product. Price is established by the Alberta Blue Cross and listed in the Alberta Blue Cross Drug Price List. Base price applies to drugs not listed on ADBL

Question 8

The Manufacturer List Price and Base Price are essentially what?

Answer 8

Two different formularies