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M9 L1
Layman's terms M9 L1 Vocab
| Term | Definition |
|---|---|
| Third-party programs | Insurance programs (private or government) that help pay for a patient’s medications |
| Who are the parties involved in a third-party program? | The patient (receives care), the pharmacy/provider (gives care), and the insurance company (pays for care) |
| Deductible | The amount a patient must pay out-of-pocket before insurance starts paying |
| Indemnity plan | Insurance that pays the patient back after they pay for medical services |
| Traditional indemnity plan | Patient pays first, then sends a claim to insurance for reimbursement; no provider network |
| Managed indemnity plan | Patient can choose any provider but may need approval and still pays part of the cost |
| Managed care plan | Insurance pays providers directly and uses a network to control costs |
| Health Maintenance Organizations (HMOs) | Plans that require patients to use in-network providers and usually don’t cover out-of-network care |
| Preferred Provider Organizations (PPOs) | Plans that cost less in-network but still allow out-of-network care at a higher cost |
| Tiered coverage | Costs vary by level; lower cost in-network and higher cost out-of-network |
| Pharmacy benefit manager (PBM) | Company that manages prescription benefits, processes claims, and controls drug costs |
| Audit | Formal review to check records and accuracy |
| TRICARE | Health insurance for military members, retirees, and their families |
| Workers’ compensation programs | Insurance that covers medical care for job-related injuries |
| Medicaid | State-run insurance for low-income patients with federal support |
| Medicare | Federal insurance for people 65+ and certain disabled individuals |
| Medicare Part D | Prescription drug coverage under Medicare with premiums and cost-sharing |
| Out-of-pocket expenses | Costs the patient pays themselves like copays, deductibles, and coinsurance |
| Medicare A | Covers hospital stays |
| Medicare B | Covers doctor visits and Durable Medical Equipment (DME) |
Created by:
RGVCPharmily
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