Payer Landscape
A percentage of healthcare service or prescription benefit that the patient is responsible for paying
What is coinsurance?
A group of healthcare industry companies and professionals working together to provide healthcare at affordable rates & at the same time control the costs of these services
What is an MCO or Managed Care Organization?
A nonprofit charitable organization that helps patients with financial need receive their prescribed Lilly medications at no cost
What is Lilly Cares?
This acronym refers to assistance provided for people with limited income on Medicare to pay for out of pocket costs for prescription drugs
What is LIS or Low Income Subsidy?
This mechanism refers to when insurance companies require the use of a particular medication first before approving another
What is a Step Edit?
A digital record of a patients chart or medical history
What is an EMR or Electronic Medical Record OR What is an EHR or Electronic Health Record?
Use this tool on your iPad to show up-to-date HCP specific payer landscape information based on their patient population
What is the IVA Formulary?
This sweet treat used to describe the percentage Medicare patients pay until total drug costs reach catastrophic coverage
What is the donut hole or coverage gap?
A health plan cost-control process by which HCPs must obtain advance approval before a specific service or medication will qualify for payment coverage
What is a Prior Authorization?
A 3rd party managing prescription drug benefits on behalf of health plans
What is a PBM or Pharmacy Benefit Manager?
This tool can be used to create specific payer leave behinds for your HCPS
What is One Connect formulary?
You qualify for both Medicare and Medicaid
What is Dual Eligible?
This is a level of cost for your medication
What is a tier?
A list of medications that are available without a prior authorization
What is a PDL or Preferred Drug List?
Used to reduce or eliminate out of pocket prescription costs for a patient, often used in lieu of samples when initiating a patient on new therapy
What is a voucher?
Federally funded drug coverage for elderly and some disabled
What is Medicare Part D?
A drug list established by Payer or Pharmacy Benefit Manager
What is a formulary?
A federal law that protects patient sensitive information from being shared without their consent
What is HIPAA or Health Insurance Portability and Accountability Act
This resource can help office staff assist their Medicare eligible patients find extra help when paying for their medications
What is Checklist: Eligibility for Medication Assistance Programs (PP-LD-US-2222)?
You could use this resource when an HCP says they don’t prescribe your medication for their elderly patients because it’s too expensive
What is the Medicare Part D Coverage Gap Discount Program (PP-MH-US-0506)?