Health Insurance Jeopardy Part 1: Prescription Drugs

Hello, my name is Karl Cooper and I’m the project manager for the National Disability Navigator Resource Collaborative at the American Association on Health and Disability and this is our presentation Health Insurance Jeopardy part 1
prescription drugs. For those of you unfamiliar with the National Disability Navigator Resource Collaborative (or NDNRC), it’s the mission of the NDNRC to provide cross disability information and support to navigators
and another enrollment specialists thereby ensuring people with
disabilities receive accurate information when selecting and enrolling in insurance
through the Affordable Care Act marketplaces I always say that when a consumer is
looking at plans on the ACA marketplace, it is like playing a game of Health Insurance Jeopardy. I say that because those of you familiar
with the game show know that in Jeopardy it’s not about the
answer it’s about asking the right question and consumers need to make sure they are
asking the right questions about the plans being offered in order
to make an informed choice. So let’s play our game. Today we’re going
to be looking at the category “Prescription Drugs.” In this first scenario, let’s assume
you meet an individual that has a disability that causes spasms. In this instance, you need to ask the
question “does the individual take medication to
treat the condition?” and let’s assume that the individual
tells you that yes, they do take a prescription muscle relaxant. If they do
then you need to ask the question how do you find out what medications are
covered by the qualified health plan or QHP? and in this instance the answer usually comes on the drug formularies that most of us are familiar with Let’s assume then that the individual takes the
prescription muscle relaxant, you’re looking at the drug formulary. Then you need to ask the question does the QHP have a tiered prescription medication benefit? A tiered prescription medication benefit
just means that they treat different drugs differently and therefore many times have
different co pays or co-insurances related to it. The
most common of these known in drug situations is the generic
verses brand-name drugs and how the plans treat those differently for co
pays but there’s other tiers as well including preferred drugs or specialty drugs and in those
instances you need to find out exactly where the person’s drug is going to fall in which tier
so you know exactly what copay they’re going to end up paying and really make the best decision
financially about which plan they should enroll in as the copays might affect
the bottom line up what they end up paying out over the course of the year. Let’s assume once again this same
individual still takes the prescription muscle relaxant. You’ve looked at the drug
formulary. You’ve looked for the tier. Now you need to also asked the question whether the QHP requires pre-authorization for the medications. In other words does the insurance
company have to give the okay before the individual goes ahead and puts in the prescription
and tries to get that prescription filled. In those instances, it’s very
important lots of times if someone is getting close to being at the end of their
medication if this is in that process, your really need to be concerned
about the continuity of care and if there’s an issue with them needing
pre-authorization and maybe having to go to the doctor for the pre-authorization then there really becomes an issue of
whether or not the person really should be enrolling in that kind of
plan because that continuity of care may get interrupted and therefore may not necessarily be the
best plan for that individual. This same individual tells you that he
has tried generic drugs before and they were ineffective. In this instance, you need to ask
whether the qualified health plan requires a patient to try a generic drug
first commonly known as step therapy and step
therapy does exactly that. It requires a patient to try the generic drug before
going to the brand name drug. If the individual has already gone through
that then once again due to the continuity of care and
making sure the person is staying on the drug that they’re on, that might not necessarily be the
best plan for them or see if there’s a way that an exception can be made when the
individual has already tried that on a prior plan or under a prior situation. If you’re interested in finding out more about the NDNRC, you can check out our web
site which is You can also find my contact information on this slide. Feel free to reach out to us if you have
questions as your assisting an individual with a disability enroll in health insurance. Also please
subscribe to our YouTube channel to get more helpful videos like this one and if you’re interested in learning
about the other categories that were listed, be sure to check out the links for the
description below to access those videos. Thank you!

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