Prescription Coverage
What are the four prescription drug stages
What is Deductible, Initial, Coverage Gap, and Catastrophic.
What is LEP short for?
Late Enrollment Penalty.
How does the deductible phase work on a prescription drug plan, and does every plan contain these?
The member will pay full price for medications up to the point of the deductible set to the account.. Example the member would pay the first $200 out of pocket if that was the set deductible amount.
No, not every plan has a deductible.
How can you assist a member when they have an LEP issue?
Complete an LEP attestation
What is LIS, and how does it affect a member?
Low Income Subsidy. It is a federal program that helps offset the cost of the members medication at a reduced set rate.
Why would a member be assigned an Late Enrollment Penalty on their account?
If a qualifying Medicare member went without credible prescription drug coverage for a period of 63 days or longer.
Member calls and states that their medication is normally $47 to obtain, but their pharmacy advised the cost this fill would be over $300, what has happened?
The member has entered the Coverage gap, also known as the doughnut hole. This is the stage where the member has a responsible cost of 25% of the price of the medication.
How long is the Late Enrollment Penalty assessed to a member?
Lifetime of a member as long as they have a medicare plan that has prescription drug coverage attached to it.
What is a cross over claim?
This is where the member crosses from stage into another in a single claim. This results in the member paying more for their medications depending on which two phases they cross from and to.
When would you refer a member to C2C ?
If a member already has been assessed the LEP to their account, or it has been more than 90 days since the letter was sent.