Term | Definition |
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. |