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angel's finance iss
angel's PhT financial issues
| Question | Answer |
|---|---|
| third party program | another party, apart from the patient or the pharmacy, that pays for some or all of the cost of medication; an insurer |
| PBM | pharmacy benefit manager |
| PBM | a company that administers drug benefit programs for insurance companies, HMOs, and self-insured employers |
| co-insurance | an agreement between the insurer and the insured to share costs |
| co-pay | the portion of the cost of medical services and prescriptions that must be paid by the insured (i.e, the individual insured by third-party insurance |
| deductible | a set amount that must be paid by the set amount for each benefit period (usually one year), before the insurer will cover additional expenses |
| MAC | maximum allowable cost |
| MAC | the amount paid by the insurer is not equal to the retail price usually charged, but is determined by a formula described in a contract between the insurer and the pharmacy |
| MAC | largest amount of money an insurer is wiling to pay per dispensing unit (per tablet, per vial, etc) that an insurer or PBM will pay for a given product |
| U&C | usual and customary |
| U&C | uses MAC to calculate the cost of a prescription within a given area; also the UCR price for the prescription |
| UCR | usual, customary and reasonable |
| prescription drug benefit card | a card containing the necessary prescription billing information, including patient ID#, group# and co-pay amount |
| HMO | health maintenance organization |
| HMO | health care networks that usually do not cover expenses incurred outside the network and often require generic substitution |
| POS | point-of-service |
| POS | healthcare network in which the patient's PCP must be a member and costs outside the network may be only partially reimbursed |
| PPO | preferred provider organization |
| PPO | health care network that reimburses expenses outside the network at a lower rate than inside the network and usually requires generic substitution |
| worker's compensation | compensation for employees accidentally injured on-the-job |
| Medicare | federally-funded program to provide health insurance for 65+, disabled of any age, patients with kidney failure |
| Medicaid | federally- and state-funded program for the needy and children deprived of the care of at least one parent |
| adjudication | insurance claim that is filed using online claim submission; in this way, the computer determines exact coverage for each Rx with appropriate 3rd party |
| DAW | dispense as written |
| DAW | series of insurance codes that refers to the reason for submitting a patient's claim for insurance payment for a name-brand medication (rather than the generic) |
| patient ID number | number assigned to patient by the insurer that is indicated in the insurance drug benefit card. |
| age limitations | many Rx durg plans have age limitations for dependents of the plan-holder |
| refills | most third-party plans require that most of the dispensed medication be taken before the insurer will cover a refill for the same medication |
| maintenance medications | under managed care programs, these Rxs may be required to be filled by mail-order pharmacies |
Created by:
a-ray
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