Module 3

Course Description

Purpose

• This module expands on the information discussed in Module 2 about insurance and public drug plans. Its purpose is to give you the specific information you will need to work with these plans effectively in coordinating coverage for patients. This is “the essentials” of navigation.
• This module is divided into two sections – private insurance plans and public plans. You may wish to break up your learning on each of these sections over two different days.

The purpose of this module is to help you understand: 

• How drug plans operate (structure, processes, key contacts, etc)
• How to work with drug plans to coordinate coverage
• How to navigate plan limits and appeals

Learning Objectives

By the end of Module 3a – Private Insurance Plans you will be able to:

• Describe the different types insurance drug plans
• Describe how insurance drug plans can vary among patients
• Identify the different contacts for insurance drug plans & when to contact them
• Identify the information you need to collect to conduct a coverage inquiry
• Describe how to determine drug availability and coverage
• Describe the methods used for drug claims and Prior Authorization review
• Outline the steps to take to deal with plan limitations or requirements
• Identify the methods that can be taken to appeal coverage decisions

By the end of Module 3b – Public Plans you will be able to:

• Describe the role of public plans in Canada

The content in this module will provide a foundation for later modules.  It is important, even if you aren’t new to the role, to review the content in its entirety.