Key Terms
A benchmark price used to estimate the cost of drugs, often higher than what pharmacies actually pay.
AWP
A process that determines which insurance pays first when a person has multiple plans.
Coordination of Benefits (COB)
A savings account used to pay for medical expenses with tax advantages.
Health Savings Account
Covers outpatient services like doctor visits.
Medicare Part B
The real-time processing of insurance claims to determine coverage and costs
Online Adjudication
Coverage that protects against very high medical costs after a certain spending limit is reached.
Catastrophic Insurance
A fixed amount a patient pays for a medication or service.
Copayment
A coding system used to classify diseases and medical conditions.
ICD-10
Provides prescription drug coverage
Medicare Part D
A provider not contracted with an insurance plan , usually costing more
Out-of-Network Provider
A program that lets people keep their employer health insurance after leaving a job, usually at their own cost.
COBRA Insurance
When a patient has two insurance plans and may have two copay responsibilities.
Dual Copay
Doctors or pharmacies that have contracts with an insurance plan for lower costs.
In-Network Providers
Supplemental insurance that helps cover costs not paid by Medicare.
Medigap Insurance
A type of insurance plan that offers flexibility in choosing providers.
Preferred Provider Organization
The percentage of costs a patient pays after meeting their deductible.
Coinsurance
A person who qualifies for both Medicare and Medicaid.
Dual Eligible
A government program that provides health coverage for low-income individuals.
Medicaid
The amount paid each month to keep insurance coverage active.
Monthly Premium
A list of medications covered by an innsurance
Preferred Drug List
Health insurance provided by private companies rather than the government.
Commercial Insurance
Medical equipment used at home, like wheelchairs or oxygen tanks.
Durable Medical Equipment (DME)
Covers hospital stays and inpatient care.
Medicare Part A
A unique number assigned to healthcare providers.
NPI
A company that manages prescription drug benefits for insurance plans.
Pharmacy Benefit Manager