Patient Led Classes

Step therapy, also known as 'fail first', is a practice used by health plans to control costs. Step therapy prevents patients from accessing a treatment prescribed by their physician by requiring them to try one or more alternative treatments first. Once those treatments have been proven ineffective or harmful to the patient, then they can step up to the treatment originally prescribed by the physician.

Precision medicine is "an emerging approach for disease treatment and prevention that takes into account individual variability in genes, biomarkers, DNA - things in your blood and tissues. environment, and lifestyle for each person." It can help with diagnosis and more accurately predict which treatment and prevention strategies for a particular disease will work for certain groups of people.

Prior authorization, also known as preauthorization is a process by which a medical provider must ask permission, or authorization, from the insurance company before performing a medical procedure or providing a medication.  Prior authorization is not a promise that a health insurer will cover the cost.

The federal drug discount program created by Congress under Section 340B of the Public Health Service Act in 1992. It requires drug manufacturers to enter into pricing agreements with the federal government under which they agree not to sell covered outpatient drugs to participating providers above 340B ceiling prices.

A process where states, often through Prescription Drug Affordability Boards (PDABs),  evaluate the costs of prescription drugs to improve affordability for consumers and manage healthcare spending.

Programs designed by for-profit third-party vendors that exclude  coverage for certain high-cost, specialty medications and direct patients to alternative funding sources like manufacturer patient assistance programs, where the vendor diverts all of the available assistance to their bottom line.

A Pharmacy Benefit Manager (PBM) is a third-party administrator that manages prescription drug benefits for health plans and employers.  In addition to processing claims, PBMs negotiate drug prices, create lists of preferred medications and pharmacy networks,  and establish cost-containment protocols. PBMs play a key role in the healthcare system.

Copay accumulators are a complex topic that can be overwhelming in the patient journey, so we have broken down what you need to know to understand them