Why does insurance status matter?
how the patient is currently paying for their medications
- Government funded (Medicare or Medicaid)
- Commercial or Private (Employer)
- No insurance
Government Funded (Medicare or Medicaid)
Medicaid (state funded for poor/low income)
- Short Term: refer for discounted medication options
- Long Term: 340B pharmacy or charitable pharmacy or FQHC
Medicare (federal funded for elderly)
- If med is not covered: PA
- If med is too much: refer for discounted medication options
MEDICAID/MEDICARE WILL NOT ALLOW COPAY CARDS
Commercial or Private Insurance (Employer)
- Find root cause of unaffordability
- expensive copay
- medication not covered at all - Verify what Tier the medication is on the patient’s insurance formulary or if it is not formulary
- High Tier (insurance has preference or different agent): provide patient with name of preferred agent
- Low Tier (patient has preferred agent): manufacturer copay card or discounted medicated options
Tier
how preferred a drug is for insurance
Tier 1
most preferred
Tier 4/5
least preferred, higher copay
Copay Cards
- supplied by manufacturers to reduce the insurance copay when used with private/commerical insurance
Tips:
- cover BRAND, not generic
- temporary solution (limit how much is covered)
- strict rules with insurance plans
Symbol: scissors with dotted box
No insurance
- Discount lists (walmart 4$ list)
- Discount cards (GoodRx)
- Medication Assistance Programs
Example of Discount Lists
Walmart Rx Program
- 4$ for 30 day fills
- 10% for 90 day fills
Kroger Health Savings Club (annual membership)
Walgreens Prescription Savings Club (annual membership)
Example of Discount Cards
GoodRx
- based on pharmacy, medication, quantity
NeedyMeds
- discount cards, same for any pharmacy
Medication Assistance Programs
- a program via the drug manufacturer who supplies medications for free (low cost) for specific patients
Criteria:
- no insurance
- medicare patients with expensive copays and low income
- low income
AVAILABLE FOR MEDICARE AND MEDICAID
Symbol: two pills
