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Mini-Med 2019 Feb

Mini-Med 2019 Feb

Mini-Med #1 2019- Stephanie Taylor MD PhD

Medical Care Systems-How to Access Care


What the insurance policy covers-specifics are in the contract and are not negotiable. Medications, radiology and procedures are often covered but may need special permissions before coverage is activated.


Cost depends on the FORMULARY TIER.

Tier 1 is the least expensive and Tier 4 the highest. Non-listed medications are non-formulary.

If the formulary medication is unacceptable for a medical reason, the physician can ask for a Prior Authorization or Tier exception.

To get the best price, fill prescriptions at the PREFFERED Pharmacy. Here is an example:

MEDICATION DRUG TIER Cost and Requirements/Limits

lisinopril Tier 1-preferred generic drugs $1(preferred retail), $19 (Standard)
telmisartan Tier 3-preferred brand name drugs $30 (preferred retail), $47 (Standard)
remicaide Tier 4-non-preferred drugs $444 (preferred), $500 (Standard)

QL=Quantity limits means there are limits on the amount of drug that will be covered in a specific time period.

ST=Step Therapy means trial of preferred drug required before insurance will cover another drug.

PA= Prior Authorization means your physician must get approval from the insurance company before you can fill your prescription.

Prior Authorization: Health plans use PA to restrict access to costly drugs and services. In 2010 the AMA surveyed 2,400 physicians about PA hassles. This is uncompensated work which means higher medical office overhead. If A Woman’s Wellspring hired a ½ time staffer to obtain insurance permissions, we would need to raise your annual fee by at least $100.00. The estimated costs of this system to a medical office is: 20 hours per week and that translates (in a very large busy practice with 6,000 patient visits/MD/year)) to an average cost of $82, 975 annually per physician.

 Procedures may also require prior authorization; for example, sleep studies, MRI and CT scanning. Each insurance company has a different system that can change annually. Prior Authorization affects both commercial insurance and Medicare (PDP) patients.



You use your Medicare card for most care. Part A of the card is for hospitals, and Part B is for medical coverage. Original Medicare (Parts A and B), is provided by the Federal Government. There are also Medicare Advantage Plans that bundle A, B and D into a “Plan C”.


There is a separate card and plan for prescription drugs called “Part D”. These plans help with the cost of medications. Original Medicare does not cover prescription drugs and these plans are purchased from private insurance companies. On the Medicare.gov website there is an excellent program to help you compare drug plans. You can get specific assistance locally from the Alliance on Aging.


You can also purchase a Medicare supplement insurance plan (Medigap) from a private insurance company. After Medicare pays it’s 80%, the supplemental plan covers the remaining 20%. These plans do not over expenses that are not eligible and paid for by Medicare.