Coinsurance

The out-of-pocket cost of medications based on a percentage of the medication price, designed to shift more of the cost onto the patient.

Continuity of Care

Continuity of care is concerned with quality and consistency of care over time, and the process through which patients, in coordination with their physicians, manage their health care. Continuity of care for patients with chronic conditions improves health, prevents hospitalizations, reduces health care costs.

Copayment

A fixed cost for prescription medication. For example, some medications cost 10 dollars for a thirty day supply.

Non-Medical Switching

Commercial health plans and pharmacy benefit managers (PBMs) are increasingly switching the medications of stable patients with complex, chronic, or rare medical conditions for non-medical reasons, including to increase the profits of a private insurer. Switching stable patients for non-medical reasons places patients at unnecessary risk and increases healthcare costs.

Prescription Drug Benefits

Benefits received through your insurance plan that relate to what medications you may receive and at what price. Depending on what health plan you have, you will have different benefits available.

Pharmacy Benefit Manager (PBM)

An intermediary between the payer and everyone else in the healthcare system. They generally make money through service fees from large customer contracts for processing prescriptions, operating mail-order pharmacies, and negotiating with pharmacies and drug makers. Their contracts can include incentives for cutting costs.

Specialty Tiers

An additional pricing category created by health plans; newer, more complex treatments that treat conditions such as cancer, arthritis, MS, HIV, hepatitis C and others are often placed on specialty tier, subjecting patients who use them to higher out-of-pocket costs by utilizing coinsurance.

Specialty Drugs or Specialty Medication

Specific medication defined as high-cost prescription drugs that treat complex conditions, which may need special handling.

Tier, Tiering, or Tiers

A health insurance pricing practice that places drugs into groups based on criteria determined by the insurer.

Utilization Review

A practice in which insurers control costs by preventing patients from accessing the treatments they need through protocols including step therapy and prior authorization.