Health Benefit Design

Why are some health treatments covered by insurance, while others are not? Why do some treatments have higher copays than others? These considerations are a result of how health benefits are designed.

There are many different approaches to health benefit design, but an overarching goal for most organizations is to realize the best value for their health care dollar while improving the quality of health care services and employee health. Among health care stakeholders, there is much debate about how to provide care with the right payment incentives, as well as about how to create incentives that reward quality rather than the volume of services provided. In recent years, the National Pharmaceutical Council has undertaken research examining some of these issues around how health benefits are structured, including value-based insurance design, consumer directed health plans, the role of pharmaceuticals in accountable care organizations, and impact on health and productivity or wellness programs, among other topics.

Health Insurance Exchanges/Marketplaces

State-based marketplaces will provide individuals and small businesses an opportunity to purchase private health insurance. Marketplaces also will assist eligible individuals to receive premium tax credits or coverage through other federal or state health care programs....more

Medicaid Pharmaceutical Plan Resources

Concerns about access to health care in the early 1960s led to the establishment of Medicare, Medicaid and other state medical assistance programs. NPC turned its attention to government policies relating to access to prescription drugs and developed the “Pharmaceutical Benefits Under State Medical Assistance Programs."...more

Medicare Drug Benefit

Medicare is a health insurance program for people age 65 or older, people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease. Medicare Part D allows all beneficiaries to enroll in coverage for prescription drugs....more

Value-Based Insurance Design

Under the concept of value-based insurance design, the more clinically beneficial a therapy is for a patient, the lower the patient’s cost share. VBID encourages the use of medically necessary therapies and services and reduces barriers to access for these services....more