Key Terms
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
AWP
online billing of both a primary and secondary insurer
Coordination of Benefits:
Medical Equipment: medically necessary, reusable equipment such as nebulizers, hospital beds, wheelchairs, and walkers that may be purchased in a community pharmacy or billed to medicare part b
Durable
federally sponsored insurance that partially covers the cost of outpatient doctor visits, may cover the cost of nebulizer, nebulizer medication, and diabetic supplies
Medicare Part B
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
Medigap 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 and is also referred to as catastrophic coverage
Catastrophic Insurance:
the amount that the patient is to pay for each prescription as determined by the insurance carrier
Copayment:t
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
Health Savings account:
a federal and state partnered insurance program that provides partial coverage of prescriptions, primarily for patients who are eligible for medicare
Medicare Part D
the cost a patient pays each month for health and/or drug insurance
Monthly premium:
Insurance policy when a former employer is required to keep a former employee is required to keep a former employee on the employee insurance plan at full premium cost for 18 to 36 months, the ACA guarantees such patients cannot lose coverage with job changes
COBRA Insurance
: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
Dual copay:
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
ICD-10:
the unique number assigned to the provider by the federal government to allow authorized healthcare providers to process insurance claims for reimbursement
NPI:
real time insurance claims processing via electronic wireless telecommunications
Online adjudication:
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
Coinsurance:
a patient who has both a primary and secondary insurance plan
Dual eligible:
Prescribers and pharmacies that have a contract with the insurance provider
In-network providers:
prescribers and pharmacies that do not have a contract with the insurance provider, the cost of services is generally higher
Out of network provider:
private practice prescriber that has signed a contract with the health insurer to provide services at a discounted rate
Preferred provider organization:
coverage for medical or prescription costs provided by an employer or purchased by an individual, also called private insurance
Commercial Insurance:
a state of governmental health insurance program for low income and disabled citizens
Medicaid
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
Medicare Part A
a formulary provided by an insurance company that indicates preferred prescription generic and brand name drugs and their corresponding copays
Preferred drug list:
a company that administers drug benefits for many insurance companies
Pharmacy Benefit Manager: