Transcript Copay Structure - Academy Of Managed Care Pharmacy

Principles in Practice
Copay Structure
Copyright © 2002-2005 – Academy of Managed Care Pharmacy (AMCP)
Slide 1
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Pharmacy
Benefit
Management
• An organization that manages pharmaceutical benefits for a
managed care organization, other medical providers or an
employer. PBMs contract with clients interested in optimizing the
clinical and economic performance of their pharmacy benefit.
PBM activities may include some or all of the following: benefit
plan design, creation/administration of retail and mail service
networks, claims processing and managed prescription drug
care services such as drug utilization review, formulary
management, generic dispensing, prior authorization and
disease and health management.
AMCP: Guiding Principles for Effective Electronic Messaging
Copyright © 2002-2005 – Academy of Managed Care Pharmacy (AMCP)
Slide 2
Click hereCoinsurance
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• A payment sharing agreement between the
insurance company or federal entity and the
patient, which often includes the copayment
concept of a specific amount per visit or for an
established amount of supplies (such as $10 for a
doctor visit or $5 for a 30-day prescription), or a
stated percentage (such as the patient’s 20%
responsibility of payment).
Navarro RP. Managed Care Pharmacy Practice. Gaithersburg, MD: Aspen Publishers;1999.
Copyright © 2002-2005 – Academy of Managed Care Pharmacy (AMCP)
Slide 3
Fixed
Co-Payment
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hereDollar
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• A payment that is the most common method of
member cost sharing today.
Example: $10-generic/$20-brand formulary
• The advantages of this type of payment are market
acceptance, member satisfaction, and ease of
administration.
• Disadvantages is that it is not indexed for inflation
an may contribute to excessive utilization of
benefit.
Navarro RP. Managed Care Pharmacy Practice. Gaithersburg, MD: Aspen Publishers;1999.
Copyright © 2002-2005 – Academy of Managed Care Pharmacy (AMCP)
Slide 4
Click here Deductible
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• The amount of eligible expense a covered
person must pay each year before the plan
will make payment for eligible benefits.
Example: The drug benefit would become active
after a patient has paid $200.00 in a 12 month
period, and would then cover 80% of charges in
excess of $200.00 level.
Navarro RP. Managed Care Pharmacy Practice. Gaithersburg, MD: Aspen Publishers;1999.
Copyright © 2002-2005 – Academy of Managed Care Pharmacy (AMCP)
Slide 5
Click hereSelf-Insured
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• A risk strategy that allows the potential
profit a carrier traditionally receives from
funding insurance risk to be experienced
instead by the employer. Essentially, the
health benefits are funded from internal
resources without purchasing insurance.
Navarro RP. Managed Care Pharmacy Practice. Gaithersburg, MD: Aspen Publishers;1999.
Copyright © 2002-2005 – Academy of Managed Care Pharmacy (AMCP)
Slide 6
Tiered
Design
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andBenefit
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• A benefit design that allows the member to
pay a lower copayment if generics or
branded formulary products are dispensed.
This design helps to offset a portion of the
acquisition costs and encourages generic
use and formulary compliance.
Navarro RP. Managed Care Pharmacy Practice. Gaithersburg, MD: Aspen Publishers;1999.
Copyright © 2002-2005 – Academy of Managed Care Pharmacy (AMCP)
Slide 7
Click here andTrend
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• The percent increase, including inflation
and utilization, a group experiences in total
spending on the pharmacy benefit from one
year to the next.
Copyright © 2002-2005 – Academy of Managed Care Pharmacy (AMCP)
Slide 8