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Chapter 15

Vocab Review

TermDefinition
co-insurance An agreement for cost-sharing between the insurer and the insured.
co-pay The portion of the medication's price that the patient is required to pay.
dual co-pay Co-pays that have two prices: one for generic and one for brand names.
U&C or UCR The maximum amount of payment for a given prescription, determined by the insurer to be a usual and customary (and reasonable) price.
deductible A set amount that must be paid by the patient for each benefit period before the insurer will cover additional expenses.
tier Categories of medications that are covered by third-party plans.
HMO Costs are covered only for services from in-network providers.
POS The patient's primary care physician must be a member; and costs outside the network may be partially reimbursed.
PPO Cost outside the network may be partially reimbursed and the patient's primary care physician need not be a member.
Medicaid A federal-state program, administered by the states, providing health care for the needy.
Medicare A federal program providing health care to people with certain disabilities or who are over age 65.
patient assistance program Manufacturer sponsored prescription drug programs for the needy.
worker's compensation An employer compensation program for employees accidentally injured on the job.
prior authorization A procedure to gain third-party coverage for a drug that is not automatically covered by a third-party plan.
CMS-1500 form The standard form used by health-care providers to bill for services, including disease state management services.
universal claim form (UCF) A standard claim form accepted by many insurers.
Current Procedural Terminology codes (CPT codes) Identifiers used for billing pharmacist-provided MTM services.
National Provider Identifier (NPI) The code assigned to recognized health-care providers; needed to bill MTM services.
Prescription Drug Plans (PDPs) Third-party programs for Medicare Part D.
Created by: Ms.little1