Terms to Know

Below are some important terms to know when diving deep into advocacy work.

Insurance Barriers

  • Utilization Management (UM) Protocols: UM protocols are a set of techniques used by insurance companies to manage health care costs. The protocols influence patient care through evaluation of the appropriateness and efficiency of prescriptions before granting coverage.
  • Prior Authorization: A type of UM, prior authorization is an insurance technique that requires patients to get approval for a prescription before it will be covered by their insurance. Often, prior authorizations need to be renewed throughout the year or when the plan year resets.
  • Step therapy: A type of UM, step therapy is an insurance protocol that requires patients to try and fail multiple drugs selected by the insurance plan before the insurance will cover the treatment prescribed by the patient’s doctor. Step therapy is used in an effort to control costs by having patients try the “least costly” options first. However, step therapy protocols do not always follow clinical guidelines or take a patient’s unique medical history into consideration. Patients can request an exception to a required step, but only some states have clearly outlined the circumstances under which an exception must be granted.

Out-of-Pocket Costs

  • Premium: The amount you pay for health insurance each month.
  • Out-of-pocket costs: Money you owe for a health care service or treatment. Even if something is covered by your insurance, there might still be an out-of-pocket cost because:
  • Out-of-Pocket Maximum/Limit: The maximum amount you will have to pay out-of-pocket for services/treatments during the plan year before your insurance pays 100 percent of the costs. The Affordable Care Act required certain health plans to have a set out-of-pocket maximum. However, some plans do not have an annual limit, such as short-term, limited-duration plans and Medicare Part D.
  • Copay assistance: Money that helps a patient afford their treatment by covering their share of the cost (copay or coinsurance). Copay assistance can come from a drug manufacturer or nonprofit organization. Often, copay assistance programs have requirements you must meet before you can use the program, such as a specific household income or type of insurance.
  • Accumulator adjustment programs, also called copay accumulators: Under a copay accumulator program, manufacturer copay assistance is not counted toward a patient’s deductible or out-of-pocket maximum. Patients can still use their copay assistance, however, when the assistance runs out they will still be responsible for paying their deductible and out-of-pocket maximum. This means the health plan collects the deductible twice, once from the copay assistance and then from the patient when the assistance runs out. 

    These programs are intended to counteract manufacturer assistance, which is viewed as incentivizing patients to choose more expensive medications instead of cheaper alternatives (such as generics). For people with psoriatic disease taking biologic medications, where no generic alternatives are available, copay accumulator programs increase patients’ costs and can prevent access if a patient can’t afford their deductible.

Understanding Copay Accumulator Adjustment Programs

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