We want to out that health plans may make decisions to not cover a medication or to restrict its coverage because the medication: May have dangerous or serious side effects or interactions, Isn’t approved for certain health conditions, May have limited effectiveness or is effective only certain conditions or Effectiveness or safety may not be well-established or may be in question. Coverage of a medication may also be limited because: A generic version of the medication is available or The medication is more expensive than other medications used to treat the same condition. We’ve mentioned that health plans can limit your choice of covered slide 10 medications and can change their list of covered medications one or more times a year. We also noted that, for many plans, P&T Committees Approx. .5 min are influential or decision-makers on coverage of medications. Core Concept Medication coverage gets But, it gets even more complicated… [Pause for a moment] more complicated Another way health may make it harder for you to get the right slide 11 medication is by putting some medications in a higher or level on its “tier” list of covered medications. Approx. 2 min Core Concept Commercial health insurance and Medicare Part D plans usually Health plans may put some have tiered drug lists. Drugs on the lowest tier have no or lower medications in higher “tiers” costs compared to drugs on higher tiers. and charge higher costs Out-of-pocket may take the form of copays (a set amount you have to pay), coinsurance (a percentage of the total drug cost) or a deductible (an amount you have to pay before coverage will begin or resume).
We want to out that health plans may make decisions to not cover a medication or to restrict its coverage because the medication: May have dangerous or serious side effects or interactions, Isn’t approved for certain health conditions, May have limited effectiveness or is effective only certain conditions or Effectiveness or safety may not be well-established or may be in question. Coverage of a medication may also be limited because: A generic version of the medication is available or The medication is more expensive than other medications used to treat the same condition. slide 10 Approx. .5 min Core Concept Medication coverage gets more complicated We’ve mentioned that health plans can limit your choice of covered medications and can change their list of covered medications one or more times a year. We also noted that, for many plans, P&T Committees are influential or decision-makers on coverage of medications. But, it gets even more complicated… [Pause for a moment] slide 11 Approx. 2 min Core Concept Health plans may put some medications in higher “tiers” and charge higher costs Another way health may make it harder for you to get the right medication is by putting some medications in a higher “tier” or level on its list of covered medications. Commercial health insurance and Medicare Part D plans usually have tiered drug lists. Drugs on the lowest tier have no or lower costs compared to drugs on higher tiers. Out-of-pocket may take the form of copays (a set amount you have to pay), coinsurance (a percentage of the total drug cost) or a deductible (an amount you have to pay before coverage will begin or resume).
Module-4-Teacher-Script.docx