8
Prescription Drug
Insurance in Health
Care
Learning Objectives
1 Describe the importance of insurance to address rising prescription drug costs. (Section 8.1)
2 Identify components of health insurance, and define common terms and concepts associated with health insurance. (Section 8.2)
3 Define key terms, such as average wholesale price, monthly premium, insurance policy, benefits, deductible, copayment, coinsurance, tiered copay, in-network providers, out-of-network providers, prior authorization, pharmacy benefit manager, coordination of benefits, and online adjudication. (Sections 8.1–8.6)
4 Explain the concept of tiered copayments for private commercial drug insurance programs. (Section 8.2)
5 Identify various aspects of commercial insurance and how it works. (Section 8.3)
6 Describe the multiple forms of government insurance, such as Medicare, Medicaid, and others. (Section 8.4)
7 Summarize the role of pharmacy benefit managers and the role of the technician in explaining to patients the costs and options related to insurance drug coverage.
(Section 8.5)
8 Identify the necessary information on a prescription insurance card to process claims online for various types of insurance and workers’ compensation claims, and paraphrase the role of technicians in identifying medication assistance and patient advocacy. (Section 8.6)
9Paraphrase the role of technicians in identifying and resolving errors in online adjudication. (Section 8.6)
10 Explain how to prepare a drug claim for online processing including entering specific information about each prescription filled, including the medication quantity and days’ supply of medication. (Section 8.7)
11 Summarize the role of technicians in explaining insurance drug coverage to patients. (Section 8.8)
12 Identify steps to resolve problems with audits and charge-backs. (Section 8.9)
13 Discuss how to assist financially struggling patients through medication assistance advocacy. (Section 8.10)
ASHP/ACPE Accreditation Standards
To view the ASHP/ACPE Accreditation Standards addressed in this chapter, refer to Appendix B.
Almost 90% of Americans have some type of private or government insurance for hospital, medical, and prescription drug benefits or a combination of healthcare coverage plans. Every insurance plan has its own unique eligibility and payout criteria based on deductibles and copayments.
You will need a working knowledge of all of these various health insurance programs because, in a retail or mail-order pharmacy, you will spend 20%–25% of your time entering, updating, and processing insurance-related information as well as resolving issues and educating patients.
With rising prescription costs, informed technicians can help patients through effective insurance claims processing, medication access counseling, and advocacy.
The job requires a thorough understanding of the terminology utilized and the steps in processing and reconciling claims. Though this may at times seem like burdensome administrative detail, it helps patients receive the care they deeply need. Insurance coverage can mean the difference between access or no access to lifesaving drug therapies, to affordability or crippling debt. Knowing how to process insurance claims can make a real difference in people’s lives.