Term
Caatastrophic Insurance
Catastrophic Insurance: 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.
Coordination of Benefits
Coordination of Benefits (COB): online billing of both a primary and a secondary insurance.
Health Savings Account
Health Savings Account (HSAs): 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.
Medicare Part B
Medicare Part B: federally sponsored insurance that partially covers the cost of outpatient doctor visits; may cover the cost of nebulizer, nebulizer medication, and diabetic supplies.
Online Adjudication
Online Adjudication: real-time insurance claims processing via electronic wireless telecommunications.
AWP
AWP (Average Wholesale Price): 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.
Copayment
Copayment (Copay): the amount that the patient is to pay for each prescription as determined by the insurance carrier.
ICD-10
ICD-10: the International Classification of Diseases, 10th revision; a coding system used by physicians and insurance companies to offer billing codes for specific diagnoses and diseases.
Medicare Part D
Medicare Part D: a federal- and state-partnered insurance program that provides partial coverage of prescriptions, primarily for patients who are eligible for Medicare.
Out-of-Network Provider
Out-of-Network Provider: prescribers and pharmacies that do not have a contract with the insurance provider; the cost of services is generally higher.
Cobra Insurance
COBRA Insurance: insurance policy when a former employer is required to keep a former employee on the employer’s insurance plan at full premium cost for 18 to 36 months; the ACA guarantees such patients cannot lose coverage with job changes.
Dual Copay
Dual Copay: 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.
In-Network Providers
In-Network Providers: prescribers and pharmacies that have a contract with the insurance provider.
Medigap Insurance
Medigap Insurance: private insurance coverage in addition to Medicare Part B that covers a portion of the costs for outpatient physician visits as well as laboratory and X-ray fees not covered by Medicare Part B.
Preferred Provider Organization
Preferred Provider Organization (PPO): private practice prescriber that has signed a contract with the health insurer to provide services at a discounted rate.
Coinsurance
Coinsurance: a percentage-based insurance plan in which the patient must pay a certain percentage of the prescription price; commonly used in high-cost specialty drugs.
Dual Eligible
Dual Eligible: a patient who has both a primary and secondary insurance plan.
Medicaid
Medicaid: a state governmental health insurance program for low-income and disabled citizens.
Monthly Premium
Monthly Premium: the cost a patient pays each month for health and/or drug insurance.
Preferred Drug List
Preferred Drug List: a formulary provided by an insurance company that indicates preferred prescription generic and brand name drugs and their corresponding copays.
Commericial Insurance
Commercial Insurance: coverage for medical or prescription costs provided by an employer or purchased by an individual; also called private insurance.
Durable Medical Eqiupment
Durable Medical Equipment (DME): medically necessary, reusable equipment such as nebulizers, hospital beds, wheelchairs, and walkers that may be purchased in a community pharmacy or provided by Medicare Part B.
Medicare Part A
Medicare Part A: 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.
NPI (National Provider Identifier): the unique number assigned to the provider by the federal government to allow authorized healthcare providers to process insurance claims for pharmacy reimbursement.
Workers’ Compensation
Workers’ Compensation: insurance provided for a patient with a medical injury from a job-related accident; also called workers’ comp or workman’s comp.