Glossary

A

Access to Care - A member's ability to obtain medical or behavioral health care. It is determined by factors such as the availability of appointments, the location of offices and facilities, hours of operation, and accommodation of cultural and linguistic preferences.

Accreditation - Accreditation programs give an external opinion on quality in programs and services as reviewed against a set of industry-derived quality standards.

Accumulators - This tool tracks your copays, coinsurance, out-of-pocket maximum and certain benefits (e.g. , day limits on certain benefits). The accumulators reset each year.

Acute - A word used for a serious and sudden condition that lasts a short time and is not chronic. Examples include a heart attack, pneumonia or appendicitis.

Adjudication - A claim review step that compares claims to covered services on a plan and determines the amount of payment, if any, for that claim. Also called adjustment. With our Mail Order Pharmacy, adjudication is part of the claims processingA claim review step that compares claims to covered services on a plan and determines the amount of payment, if any, for that claim. Also called adjustment. With our Mail Order Pharmacy, adjudication is part of the claims processing system and takes place at the time a prescription is dispensed. system and takes place at the time a prescription is dispensed.

Adverse Drug Reaction (ADR) - Occurs when a particular drug is harmful to a patient.

Allergy Treatment - Medical treatment by or under the direction of a physician for allergies, which may include testing, evaluation, injections, or administration of serum.

Analgesics - The therapeutic drug class that includes medications used to relieve pain.

Anti-infective Agents - Medications that are in the therapeutic drug class used to treat infectious diseases such as community-acquired pneumonia.

Antineoplastic Agents - Medications that are used to treat cancer.

Appeals - A formal process where a member and/or provider requests that a decision about medical necessity is revisited and potentially changed.

Attention-Deficit Hyperactive Disorder (ADHD) - A condition affecting children and adults characterized by difficulty maintaining attention, with or without concurrent impulsivity and high levels of motor activity. It affects between three and seven percent of school age children, and between two and four percent of adults.

Authorization - Approval of care required before a service is provided. Members may have to pay for non-approved treatment. Note: Your prescription vendor uses pre-approved criteria, developed by our Pharmacy and Therapeutics Committee, and reviewed and adopted by your health plan, to provide authorizations for claims using real-time edits. For certain types of drugs, Prior Authorization is required. Also see Pre-Authorization or pre-approval.

B

Behavioral Health - This is also called mental health. It describes a person's state of mind. Depression, eating disorders and substance abuse are conditions that fall under this term.

Benefit Limit - A predetermined amount of pharmacy benefit expenses that your plan sponsor will cover before you must pay for your medications at 100%. In most cases, the plan sponsor paid amount is tracked and, once your benefit limit is met, you are responsible for a 100% copayment amount.

Benefit Period - The period of time for which we pay Benefits for Covered Services rendered while the Health Benefit Plan was in effect.

Benefits - Health care services, supplies, drugs, and equipment that are medically necessary and covered under the terms of the Health Benefit Plan. Benefit payments may be paid to the Member (or Subscriber), or on his behalf to the medical provider. Exact benefits depend upon your specific plan and include limits e.g. , number of visits, percentage paid or dollar maximums applied, subscriber responsibility (cost sharing components), or Subscriber incentives to use network providers.

Brand Name Drug - Prescription drugs that are manufactured and marketed under a registered trade name or trademark. Your health plan's Formulary provides access to brand name drugs, as well as generic drugs.

C

Cardholder - The primary person maintaining the pharmacy benefit coverage and, as such, is issued the pharmacy benefit card in their name. Also referred to as a covered individual or member.

Cardholder Number - A unique number that appears on a pharmacy benefit card that identifies the cardholder. Also referred to as an identification number.

Cardiovascular Agents - Drugs in the therapeutic class of medications that are used to treat cardiovascular conditions such as heart failure, high blood pressure, etc.

Central Nervous System (CNS) Therapeutic Class - The class of medications that are used to treat central nervous system conditions such as convulsions, depression, or Parkinson's Disease.

Chemical Dependency - Occurs when a user has taken a chemical substance frequently enough to produce clinically important distress or impaired functions. Chemical dependency does not have to be intentional; it can develop from medicinal use, such as the treatment of chronic pain.

Chemotherapy - This is a cancer treatment. It involves chemical or biological drugs. These drugs are usually given through a vein.

Chronic - A word used for a condition that is long term and ongoing, and is not acute. Examples include diabetes, asthma, allergies and hypertension.

Claims - Information submitted by a provider or covered person to establish that medical services were provided to a covered person, from which processing for payment to the provider or covered person is made.

CoInsurance - A fixed-dollar amount or a percentage of the total drug cost (also known as coinsurance), set by your plan sponsor, that you must pay each time you obtain a covered medication. Sometimes a copayment can also be a combination of a fixed dollar amount and a percentage of the total drug cost.

Complaint - An oral or written expression of dissatisfaction, including any complaint dispute request for reconsideration or appeal. A complaint is also known as a Grievance.

Compliance - Adhering to agreed upon rules and guidelines. Your health plan's prescription vendor uses compliance in several contexts: For members, compliance generally means using drugs in compliance with written instructions. For physicians, Formulary Compliance means writing member's prescriptions for drugs in your health plan's Formulary. Pharmacy Audit Compliance means complying with guidelines for network contracts and following audit procedures.

Consumer Driven Health Plan (CDHP) - A health plan that educates people about costs so they can make informed decisions. CDHPs usually offer a compatible Health Reimbursement Account or a tax-advantaged Health Savings Account with a qualified high deductible health plan.

Contraception - Voluntary prevention of conception or pregnancy.

Controlled Substances - Medications that the U.S. Food and Drug Administration have classified as potentially habit-forming or addicting. The FDA categorizes controlled substances as Schedule II, III, IV and V, based on their level of potential for physical and/or psychological addition. Schedule V are the least addictive, and Schedule II are the most addictive, controlled substances.

Coordination of Benefits (COB) - The provision which applies when an Member is covered by multiple Health Benefit Plans at the same time. The provision is designed so that the payments by all plans do not exceed 100% of the Covered Services. The provision also designates the order in which the multiple Health Plans are to pay benefits. Under a COB provision, one plan is determined to be primary and its benefits are applied to the claim first. The unpaid balance is usually paid by the secondary plan to the limit of its responsibility. Benefits are thus coordinated among all of the Health Benefit Plans.

Copayment - A fixed-dollar amount or a percentage of the total drug cost (also known as coinsurance), set by your plan sponsor, that you must pay each time you obtain a covered medication. Sometimes a copayment can also be a combination of a fixed dollar amount and a percentage of the total drug cost.

Copayment Tier - A tier usually represents the copayment level that applies to a certain formulary status and medication type (i.e. , Tier 1: formulary/preferred generic, Tier 2: formulary/preferred brand, Tier 3: non-formulary/non-preferred brand, or Tier 4: specialty medications).

Cost Containment - Strategies that aim to reduce health care costs and encourage cost-effective use of health care services. Our Mail Order Pharmacy's Cost Management Strategies are designed to provide cost containment while maintaining a high standard of quality care.

Cost Sharing - A provision of the pharmacy benefit that requires you to pay some portion of the cost of the product or service. Examples of cost-sharing include copayments and deductibles.

Cross Brand - Brand name drugs which have the same chemical ingredients and are therapeutically equivalent, but are marketed under two or more different registered trade names or trademarks.

Customer Service Associate (CSA) - Frontline representative responsible for managing and routing member calls while providing excellent customer service. It is the goal of a CSA to resolve member and provider needs in the first call.

D

Deductible - A predetermined amount that you must pay for your medications before your pharmacy benefit coverage begins. In most cases, your paid amount is tracked and, once the deductible is met, you are responsible for your copayment amount only.

Dependent - This is a person who is covered by another person's plan. It can be a child, spouse or domestic partner.

Dependent Coverage - Dependents of the primary cardholder who are eligible for pharmacy benefit coverage. The plan sponsor determines the eligibility rules for covering dependents.

Dermatological Therapeutic Class - The class of medications that are used to treat skin diseases.

Diagnostic/Diagnosis - When a doctor identifies a condition, illness or disease.

Direct Member Reimbursement (DMR) - Direct member reimbursement is a paper claim submitted directly by a member. This method of reimbursement is used when a member has to pay full price for a drug or does not have their drug identification card with them at the pharmacy store.

Disenroll/Disenrollment - When a member leaves a Health Benefit Plan.

Dispense As Written (DAW) - DAW, written on a prescription by the physician, indicates that the physician wants the pharmacy to dispense the brand medication that is written on the prescription pad.

Drug Interaction - A situation in which a substance affects the activity of a drug, i.e. the effects are increased or decreased, or they produce a new effect that neither produces on its own. Typically, interaction between drugs comes to mind (drug-drug interaction). However, interactions may also exist between drugs & foods (drug-food interactions), as well as drugs & herbs (drug-herb interactions).

E

Effective Date - The date on which the Health Benefit Plan goes into effect.

Electrolytes - Various chemicals in the body that can carry electric charges. Electrolytes are present in the blood as acids, bases, and salts and can be measured by laboratory studies of the serum.

Eligible/Eligibility - Means that a person meets certain requirements to receive benefits from programs.

Endocrine Therapeutic Class - Medications that are used to treat diseases of the endocrine system such as diabetes or thyroid conditions.

Enroll/Enrollment - When a member joins a health plan

Exclusions - These are conditions or services that the health plan does not cover.

Experimental Services or Procedures - These are often newer drugs, treatments or tests. They are not yet accepted by doctors or by insurance plans as standard treatment. They may not be proven as effective or safe for most people.

Expiration Date - The date on which coverage under the Health Benefit Plan expires.

Explanation of Benefits Form (EOB) - Are sent by payers to both enrollees and providers to explain necessary information about claims payments information and patient responsibility.

G

Gastrointestinal Therapeutic Class - The category of medications that is used to treat gastrointestinal (GI) conditions.

Gender Specifications - Coverage for certain drugs may be restricted based on your gender (i.e. , You must be male to receive Viagra).

Generic Dispensing Rule - If a generic dispensing rule applies to your pharmacy benefit and a multi-source brand name drug is dispensed, you may be required to pay the applicable copayment amount plus the difference in cost between the generic product and the multi-source brand name drug. Please refer to your pharmacy benefit materials for further clarification.

Generic Drug - A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs.

Generic Substitution - The practice of dispensing a generic equivalent instead of the brand counterpart. Substitutions can only occur when a generic equivalent is available, when the substitution is allowed by law, and when the physician has not marked the prescription "dispense as written".

Grievance - A type of complaint you make about the Plan or one of the Plan providers, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.

H

Health Insurance Portability and Accountability Act (HIPAA) - This law, which took effect on April 14, 2003, was the first-ever federal privacy standards act to protect patients medical records and other health information provided to health plans, doctors, hospitals and other health care providers. HIPAA was developed by the Department of Health and Human Services as the new standards to provide patients with access to their medical records and allow them greater control over how their personal health information is used and disclosed. They represent a uniform, federal floor of privacy protections for consumers across the country. HIPAA includes provisions designed to encourage electronic transactions and also requires new safeguards to protect the security and confidentiality of health information. The final regulation covers health plans, health care clearinghouses and specific health care providers who conduct certain financial and administrative transactions (e.g. , enrollment, billing and eligibility verification) electronically.

Health Savings Account (HSA) - A tax-advantaged savings account used to pay for qualified health care costs. The account may be funded by the employee, the employer or both. A person must be covered by a qualified High Deductible Health Plan (HDHP) to contribute to an HSA. Unused funds in the account roll over.

High Deductible Health Plan (HDHP) - A high-deductible health plan (HDHP) is a health insurance plan with lower premiums and higher deductibles than a traditional health plan. Being covered by an HDHP is also a requirement for having a health savings account. [1] Some HDHP plans also offer additional wellness benefits, provided before a deductible is paid. High-deductible health plans are a form of catastrophic coverage, intended to cover for catastrophic illnesses.

HMG-CoA Therapeutic Class - The class of drugs which includes medications used to treat elevated cholesterol levels.

Home Infusion Therapy - Receipt of Infusion Therapy at an individual's residence.

Human Immunodeficiency Virus (HIV) - The virus that affects the immune system and causes the disease known as AIDS (acquired immunodeficiency disorder).

I

I.D. Card/Identification Card - A card issued to a Subscriber and possibly his/her dependents, which allows the Member to identify himself/herself to a doctor or health care facility in order to obtain health services. The I.D. Card may contain information about the Member's Benefits.

Immunizations - Inoculations with vaccines to establish resistance to specific infectious diseases.

Infertility - Term used to describe the inability to conceive or an inability to carry a pregnancy to a live birth after a year or more of regular sexual relations without the use of contraception. Also includes the presence of a condition recognized by a physician as the cause of infertility.

Infusion Therapy - A liquid substance introduced into the body by a vein for therapeutic purposes.

Injectable Drug - This is a drug that can be put into the body with a needle or syringe. The medicine is put under the skin, into a muscle, or into a vein. It may start as a powder that is mixed with water.

Involuntary/Involuntarily - When something is done without choice.

M

Mail Order Pharmacy - A pharmacy that dispenses and delivers prescription medications directly to a members home, work, or other location. Our Mail Order Pharmacy serves health plan members nationwide. The Mail Order Pharmacy dispenses medications from its multiple facilities throughout the United States to ensure the fastest delivery possible.

Mail-order Drugs - See "Maintenance medications".

Maintenance Medications - These are prescription drugs that people take on a regular basis. These drugs help treat chronic conditions. These drugs include ones for asthma, diabetes, high blood pressure and other health conditions. Buying them through a mail-order pharmacy can save money.

Major Depressive Disorder - A condition that involves a person's body, mood, and thoughts. It has a negative effect on the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things, such that it can interfere with typical activities of daily life and a person's ability to participate in the workplace, family, and social spheres.

Malignant - This is a word to describe a tumor. It means the tumor is cancerous. It is cancer. It can grow and spread in the body. (See also metastatic or metastasize.)

Managed Behavioral Health Organization (MBHO) - program of managed care specific to psychiatric or behavioral health care.

Managed Care - The sector of health insurance in which health care services are managed through an administrative entity in order to appropriately allocate the use of benefits. Managed care organizations provide guidance on how services are administered so that they may better monitor the appropriateness of care and control health care costs for the entities that pay for the care, such as insurance companies, employers, or the government.

Maximum Allowable Cost (MAC) - Maximum Allowable Cost (MAC) is the maximum reimbursement that Primetherapeutics Pharmacy Solutions will pay to a pharmacy for each product on a specific list of generic medications (sometimes called the "MAC List").

Maximum Drug Benefit - This is a type of limit that some health plans have. It is the most the plan will pay for prescription drugs for a period of time. If a member's drug costs reach that limit within the time period, the plan will not cover the drug costs for the rest of that time.

Maximum Out-of-Pocket - A predetermined amount that you must pay for your medications before your plan sponsor will cover your pharmacy benefit expenses at 100%. In most cases, your paid amount is tracked and, once your maximum out-of-pocket expenses are met, you are responsible for a $0 copayment amount.

Medicaid - A program, funded by the federal and state governments, which pays for medical care for those individuals who could not afford it otherwise because of poverty or disability.

Medical Condition - This is a disease, illness or health problem for which you seek treatment

Medical Exception - The process by which your physician may request additional quantities of a medication or coverage of a drug excluded from the formulary if he/she deems it medically necessary.

Medical Necessity Criteria - Evidence-based criteria used by Primetherapeutics to assist clinicians in providing treatment at the most appropriate, least restrictive level of care necessary to provide safe and effective treatment and meet the individual patient's bio-psychosocial needs. At every level of care, treatment is individualized, active and takes into consideration the patient's stage of readiness to change/ readiness to participate in treatment.

Medicare - A federal program that pays for certain health care expenses for people aged 65 and older. Enrolled individuals must pay deductibles and co-payments, but much of their medical costs are covered by the program.

Medication - This is a drug a person takes. It can be a prescription drug or an over-the-counter drug.

Member - An individual enrolled and utilizing services provided by a specific organization

Member Maximum - A predetermined amount that you must pay for your medications before your plan sponsor will cover your pharmacy benefit expenses at 100%. In most cases, your paid amount is tracked and, once your maximum out-of-pocket expenses are met, you are responsible for a $0 copayment amount.

Member Services Department - The Health Plan's department that helps members with questions and concerns.

Mental Disorder - This is a problem with brain function. It affects the way people see themselves and the world they live in. It may also affect how they act.

Mental or Behavioral Health - Services are given for the diagnosis or treatment of a mental or emotional illness.

Metastatic (Metastasize) - This is a word that describes cancer. It means that the cancer has spread.

Mg - This stands for milligram. It is a very small amount used to measure drugs.

Microalbuminuria - This is a condition in which high levels of protein are found in the urine. This could signal a kidney problem.

Monitor - This means to keep track of something. For example, a doctor wants to monitor your blood pressure. That means he or she wants to watch it, check it over a period of time to make sure there is nothing wrong.

Multisource Brand Drugs - Brand name drugs which are distributed by more than one manufacturer and which also may have a generic drug counterpart available.

N

National Drug Code (NDC) - The unique, 11-digit NDC number assigned to each legend drug. The first five digits identify the manufacturer. The next four digits identify which product the drug is. The final two digits signify the package size.

Network Pharmacy - A network pharmacy is a pharmacy where members of the Plan can get their prescription drug benefits. We call them network pharmacies because they contract with the Plan. In most cases, your prescriptions are covered only if they are filled at one of the Plan's network pharmacies.

Non-Preferred Product - A drug that is not listed on the Health Plan's formulary and requires authorization from the health plan in order to be covered

Non-Sedating Antihistamines Therapeutic Class - The therapeutic class of drugs that are used to treat various conditions, most commonly to provide relief of seasonal allergic rhinitis (hay fever).

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs group) - The class of drugs that are typically used to treat arthritis, inflammation, and pain.

Notice of Privacy Practice (NOPP) - Document that informs the member how medical information may be used and distributed by the health plan.

Nutrient - This is a substance that is good for the body. It is often used when talking about food.

P

Participating Pharmacy - This is a Pharmacy that has a contract with a health plan. It fills covered prescriptions for plan members.

Patient Safety - The principle that the physical safety of patients should be a paramount consideration during the assessment and provision of treatment, and that treatment should not cause harm; an example is that the correct medication in the correct dosage is dispensed and the patient has sufficient instruction to use it safely.

Personal Health Record - This is a record of a person's health information. It can include claims and other health history. It is stored online and viewed on a computer. A health plan can add to it. It might add medical claims received and doctor visit information. People can also add their own information to it. They might add information on family health or eating habits.

Pharmacy - A pharmacy is a drug store.

Pharmacy and Therapeutics Committee - This is a group of health care professionals. Doctors, pharmacists and others are on it. The group advises a health plan company on safe and effective drug use. It also helps the plan create a formulary or preferred drug list.

Pharmacy Benefit Manager (PBM) - An organization that provides pharmacy-related products, programs and services designed to help maximize drug effectiveness and contain drug expenditures by influencing the behaviors of prescribing physicians, dispensing pharmacists, and utilizing members.

Pharmacy Copay - This is a person's share for covered prescription drugs. It is paid to a participating pharmacy. It is a set dollar amount.

Physician - A licensed medical doctor.

Plan Exclusions and Limitations - These are legal conditions. They apply to health plans. They list specifically what is and what is not covered by the plan.

Plan Maximum - This is a type of limit that some health plans have. It is the most the plan will pay for prescription drugs for a period of time. If a member's drug costs reach that limit within the time period, the plan will not cover the drug costs for the rest of that time.

Preferred Drug List (PDL) - This is a list of prescription drugs not covered by a health plan. It applies to closed formulary plans. If a member needs a drug on this list, the doctor must ask the plan to cover it as an exception. The plan will only do so if use is medically necessary.

Preferred Product - There may be more than one drug within a therapeutic category to treat your condition. Therefore, your plan sponsor designates selected drugs as preferred because of their overall ability to meet your therapeutic needs at a lower cost. If appropriate, ask your physician to consider prescribing a preferred drug.

Prescriber - A provider who legally writes prescriptions for a member.

Prescription - A doctor's order for a drug is a prescription. It is usually written. If it is a verbal order, it must be put in writing by the pharmacy.

Prescription Drug - This is a type of medicine. It must have a doctor's prescriptions before it can be sold. It is different than an over-the-counter drug. This can be bought without a prescription.

Primary Care - A basic level of health care usually rendered in ambulatory settings by general doctors, family doctors, internist, obstetricians, pediatricians and mid-level doctors. This type of care emphasizes caring for the member's general health needs as opposed to specialists focusing on specific needs.

Primary Care Physician (PCP) - A general practitioner or internist who delivers general health care, and is most often the first doctor a patient sees. This physician treats the patient directly, refers them to a specialist, such as a behavioral health clinician, if necessary.

Prior Authorization - Approval in advance to get certain drugs that may or may not be on a formulary. Some drugs are covered only if your doctor or other plan provider gets prior authorization from the Plan.

Provider - Individuals and facilities who are licensed to provide health care services (e.g., hospitals, skilled nursing facilities, physicians, pharmacists, etc.).

S

Single-Source Brand - A drug that is marketed or sold by one manufacturer or labeler, is referred to by its trade name, and is protected under patent exclusivity.

Specialty Medications - Your pharmacy benefit may include coverage for certain products that are referred to as specialty medications. These specialty medications are prescribed to treat certain conditions, such as anemia, cancer, cystic fibrosis, growth hormone deficiency, hepatitis C, multiple sclerosis, and respiratory syncytial virus. Most specialty medications are injectables or require special shipping and handling, such as refrigeration. As a result, distribution of specialty medications and additional related services are arranged by a specialty provider.

Step Therapy - An automated process that requires you to first try another drug to treat your medical condition before the Plan will cover the drug your physician may have initially prescribed based on your drug history. Step therapy usually requires the use of one or more prerequisite drugs prior to the use of another drug.

Substance Abuse - A pattern of use of substances, which can include alcohol, household chemicals, prescription drugs and illegal drugs that can jeopardize health and safety as well as disrupt a person's ability to function normally in their job, school, family, or other settings. Substance abuse may or may not lead to addiction, depending on the individual and the pattern of use.