Dco slides new hire trainingPresentation Transcript
Deductibles, CAPs, Out-of-Pocket (OOP)
DED, CAP and OOP
Commonly referred to as DCO
DED and OOP are driven by what the MEMBER pays
CAP is driven by what the CLIENT pays
Basic Example of plan Design with DCO
Deductibles/Caps/OOP Benefit Phases (Definitions)
DED and OOP are driven by what the member pays
CAP is driven by what the client pays
TERM ABBREVIATION DEFINITION Deductible, Cap, Out of pocket operations DCO ops DCO ops can be reached via email at Medco DED Group Deductible DED Deductible is the amount which the member must pay before the full prescription benefit takes effect. (Copay) Out of Pocket OOP Out of Pocket tracks the amount which the member spends, such as copay and at times the DED. Once the OOP is met the member’s copay is either lowered or eliminated based on how the client requires the benefit to be administered. Cap CAP Cap is the amount which the client chooses to cover for a benefit period (Net Check amt) Lifetime cap LTC LTC is the amount which the client chooses to cover over the lifetime of a member Drug specific cap RX specific Drug specific cap ID can be used to manage drug specific Ded, Cap and Oop benefits (inclusion and exclusion)
DCO Plan Phase Examples Basic DED, CAP and OOP only Complex DED, CAP, OOP, Life Time Cap and Rx Specific CAP
Deductibles/Caps/OOPs (Member and Family Options)
Deductibles, Caps and OOPs can apply to a single member, family, or combination.
OPTION DETAILS Individual with Family Total Applied to each member with a family total or limit. This is also knows as embedded benefits. No member will pay more than the individual limit and no family will pay more then the family limit. Individual Applied to each member in a family without a family total. Family Total Applied when any of the family members reach the total. Non-embedded Applied to individual or family benefits based on eligibility coverage code. Non-embedded options are available for DED and OOP (options N)
Individual with Family Example Claims are applied to each member with a family total or limit. This is also knows as embedded benefits. No member will pay more than the individual limit and no family will pay more then the family limit. $50 Dollar Individual Limit $75 Family Limit No member will pay more than the individual limit and no family will pay more then the family limit.
Individual Only Each claim applied to each member’s individual accumulation. Each member must meet their individual accumulation before moving to next phase.
Family Only Claims are applied to a family limit only. Once the family limit is meet every member will move into the next benefit phase .
Individual or Family (Non Embedded) Members in the same group either have a individual or family limit based on eligibility coverage code. Individual Coverage Code Family Coverage Code
Deductibles/Caps/OOPs (Claim Types)
Clients may establish Deductibles, Caps, and OOP limits for the following claim types (channels):
Retail Mail Separate
Combined – includes all retail and mail claims
Direct claims either separately or in combination (Directs default to retail unless other wise specified in the setup)
The channel of the benefits are driven by the DCO types on Client Profile screens 8, 9 and 10.
Channel Example Retail Only. Retail claims would apply to accumulation. Mail Claims would bypass phase. Mail Only. Mail claims would apply to accumulation. Retail Claims would bypass phase. Retail Mail Combined. Retail and Mail claims would apply to same accumulation. Retail Mail Separate. Retail apply to retail accumulation and Mail apply to mail accumulation.