Terms Flashcards
Co-insurance
An agreement for cost-sharing between the insurer and the insured
Co-pay
The portion of the medications price that the patient is required to pay
Maximum allowable cost (MAC)
The maximum price per tablet (or other dispensing unit) an insurer or PBM will pay for a given product
Online adjudication
The resolution of prescription coverage through the communication of the pharmacy computer with the third-party computer
Pharmacy benefit managers
Companies that administer drug benefit programs (PBM)
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
Dual co-pays
a lower co-pay applies to prescriptions filled with generic drugs and a higher co-pay applies to prescriptions filled with brand-name drugs with no generic equivalent
Deductible
A set amount that must be paid by the patient for each benefit Before the insurer will cover additional expenses
Formulary
A list of medications covered by third-party plans
Prescription drug benefit cards
Cards that contain third-party billing information for prescription drug purchases
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 cost outside the network maybe partially reimbursed
PPO
Costs outside the network may be partially reimbursed in the patient’s primary care physician need not be a member
