Key Terms
Dual Copay
What is insurance coverage in which a patient pays one copay for brand name drugs and a lower copay for generic drugs; also known as two-tier?
Medically necessary, reusable equipment such as nebulizers, hospital beds, wheelchairs, and walkers that may be purchased in a community pharmacy or billed by Medicare Part B
What is Durable Medical Equipment (DME)?
COBRA Insurance
What is insurance policy when a former employer is required to keep a former employee on the employee insurance plan at a full premium cost for 18 to 36 months; the ACA guarantees such patients cannot lose coverage with job changes?
Real-time insurance claims processing via electronic wireless telecommunications
What is Online Adjudication?
Out-of-network provider
Who are prescribers and pharmacies that do not have a contract with the insurance provider; the cost of services is generally higher?
ICD-10
What is the International Classification of Diseases, 10th revision; a coding system used by prescribers and insurance companies to offer billing codes for specific diagnoses and diseases?
Savings accounts that can be started by patients or their employers to set aside tax-deferred money specifically for healthcare costs not covered by their insurance
What is a Health Savings Account (HSA)?
Copayment (Copay)
What is the amount that the patient is to pay for each prescription as determined by the insurance carrier?
Online billing of both a primary and a secondary insurer
What is Coordination of Benefits (COB)?
Preferred Provider Organization (PPO)
What is the private practice prescriber that has signed a contract with the health insurer to provide services at a discounted rate?
Medicare Part D
What is a federal- and state-partnered insurance program that provides partial coverage of prescriptions, primarily for patients who are eligible for Medicare?
A plan that is aimed at protecting oneself from the high costs of a severe accident or unexpected, debilitating illness or disease, it has low monthly premium payments in exchange for a very high deductible (i.e., $5,000-$10,000) and is also referred to as catastrophic coverage
What is a Catastrophic Insurance?
In-network providers
Who are prescribers and pharmacies that have a contract with the insurance provider?
Dual eligible
Who is a patient who has both a primary and secondary insurance plan?
Prior Authorization (PA)
What is approval for coverage of a high-cost medication or a medication not on the insurer’s approved formulary obtained after a prescriber calls the insurer to justify the use of the drug; must be obtained before the drug is dispensed by the pharmacy to be covered by insurance?
Pharmacy Benefit Manager (PBM)
What is a company that administers drug benefits for many insurance companies?
The cost a patient pays each month for health and/or drug insurance
What is Monthly Premium?
Medicare Part A
What is the federally sponsored insurance plan that covers 80% of the cost of hospital stays, as well as limited coverage of skilled nursing facilities, rehabilitation, and home health care; drugs are not covered under this plan?
Medicaid
What is a state governmental health insurance program for low-income and disabled citizens?
Workers Compensation
What is insurance provided for a patient with a medical injury from a job-related accident; also called workers’ comp or workman’s comp?
AWP (Average Wholesale Price)
What is the average price that wholesalers charge the pharmacy for a drug, serving as the benchmark price to estimate reimbursement rates and retail price without insurance?
A formulary provided by an insurance company that indicates preferred prescription generic and brand name drugs and their corresponding copays
What is a preferred drug list?
What is the unique number assigned to the provider by the federal government to allow authorized healthcare providers to process insurance claims for pharmacy reimbursement?
Medicare Part B
What is the federally sponsored insurance that partially covers the cost of outpatient doctor visits; may cover the cost of nebulizer, nebulizer medications, and diabetic supplies?
Preferred Drug List
What is a formulary provided by an insurance company that indicates preferred prescription generic and brand name drugs and their corresponding copays?