Stream: Da Vinci PDex Drug Formulary
Topic: Copay Options
Courtney Bland (Feb 05 2021 at 20:30):
There are some plans in which the deductible is waived for one or more tiers. The member may have a deductible, but it doesn't apply for Tier 1, for example. In this case, we are choosing to use "Before deductible" for the copay option. We think this could be misleading for a member. If the member knows that he or she has a deductible of $1000 and sees "before deductible", that person may think that the deductible will be charged on that tier after the copay.
Saul Kravitz (Feb 08 2021 at 17:34):
hi @Courtney Bland
Is this the same question as this previous stream and jira tracker ?
Courtney Bland (Feb 12 2021 at 15:49):
Saul Kravitz said:
hi Courtney Bland
Is this the same question as this previous stream and jira tracker ?
Hello @Saul Kravitz . Thank you for your reply. No. This question is different. With that other issue, we are asking for a different way to handle the situation in which the deductible limit is set to $0 and there is a copay or coinsurance value. For this question, the deductible is greater than $0, but the deductible is waived on a specific drug tier. So for example, the deductible is $1000. The consumer is interested in a Preferred Generic drug. That drug tier has the deductible waived and a copay of $10. What that means is that the consumer doesn't have to meet its deductible before paying the copay of $10 and that $10 ends up applying to the deductible. The definition of before deductible is: The consumer first pays the copay, and any net remaining allowed charges accrue to the deductible. That doesn't fit this situation. In this situation, the copay goes towards the deductible. The net remaining doesn't go towards the deductible. @Mark Neumuth
Saul Kravitz (Feb 12 2021 at 16:02):
@Courtney Bland
Naive questions:
- Is this a common scenario across payers?
- Is what you are suggesting that there be a 'deductible waived' flag on the drug?
- or a text note field on each drug to describe special circumstances?
Courtney Bland (Feb 19 2021 at 15:53):
Saul Kravitz said:
Courtney Bland
Naive questions:
- Is this a common scenario across payers?
- Is what you are suggesting that there be a 'deductible waived' flag on the drug?
- or a text note field on each drug to describe special circumstances?
Hello, @Saul Kravitz
I'm sorry for the delay in responding. I appreciate your previous response. Yes, this is an industry standard for Medicare and differs from QHP, I believe. We have the same issue with coinsurance. The deductible can be waived on a tier with coinsurance. The coinsurance will contribute to the deductible in the same way as copay, even when the deductible is waived. I think a deductible waived flag would ideal as opposed to using text because it is not a rare condition for Medicare. Before deductible for the copay option seems to be meant for another scenario in which the customer pays the copay and the remaining charges go to the deductible. Using that option gives people the wrong impression. The coinsurance option value set doesn't really have anything that applies. Alternatively to adding a new option, maybe, the value sets could be made extensible. Thank you. @Mark Neumuth
Saul Kravitz (Feb 19 2021 at 16:17):
Added https://jira.hl7.org/browse/FHIR-31073. You should probably follow this one.
To track all open formulary issues, you can use this open (no login required) HL7 Issue Filter.
@Mark Neumuth @Courtney Bland
Last updated: Apr 12 2022 at 19:14 UTC
