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Insurance terms

QuestionAnswer
PBM NOT insurance
PBM pharmacy benefit manager
PBM processes insurance claims
PBM reimburses / audits pharmacies
PBM set formularies
Rejections wrong DOB / ID
Rejections refill too soon
Rejections PA required
Rejections drug not covered
Tiered Copayment Tier 1 = Generic
Tiered Copayment Tier 2 = Preferred Brand
Tiered Copayment Tier 3 = Non-preferred Brand
Premium amount paid per month to get insurance coverage
Coinsurance Insurer / patient agree to share costs; typically a %
Deductible amount the pt must pay before insurance covers costs
Copay amount paid for each prescription / service
Adjudication pharm computer compares to PBM, tells us $$ for pt to pay
 

 



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