Specialty Drugs
High-cost medications (biologics, infused therapies) placed in the highest formulary tier with coinsurance rather than copay cost-sharing.
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Practice This Concept
In a Medicare Part D plan, the 'tier' assigned to a drug on the plan's formulary indicates:
The cost-sharing level, such as the copayment or coinsurance, the enrollee pays for that drug — Part D formulary tiers rank drugs into levels that determine the enrollee's cost-sharing, generally with lower tiers carrying lower copays (for example, generic drugs) and higher tiers carrying higher copays or coinsurance (for example, brand-name or specialty drugs). The examination objectives require candidates to be able to explain formulary tiers and their importance, because tier assignment directly affects the enrollee's out-of-pocket cost. This concept is tested under AH-III.D.1g, and consumers are encouraged to review tier placement before choosing a plan.
National insurance concept
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