Pharmacy Tech Ch.8 Keyterms

**Audit-** A challenge on a reimbursement from a PBM or insurance provider on a prescription claim that has been previously processed.

**AWP (average wholesale price**)**-** The average price that wholesalers charge the pharmacy for a drug, serving as the benchmark price to estimate reimbursement rates and retail price without insurance.

**Benefit-** The provision of health and drug insurance coverage by an employer.

**catastrophic insurance-** A plan that is aimed at protecting oneself from the high costs of a severe accident or unexpected, debilitating illness or disease; it has low monthly premium payments in exchange for a very high deductible (i.e. $5,000-$10,000) and is also referred to as a catastrophic coverage.

**charge back-** A rejection of a prior prescription claim by a PBM or an insurance provider that must be investigated and resolved.

**cobra insurance-** Insurance policy when a former employer is required to keep a former employee on the employee insurance plan at full premium cost for 18 to 36 months; the ACA guarantees such patients cannot lose coverage with job changes.

**Coinsurance-** a percentage-based insurance plan in which the patient must pay a certain percentage of the prescription price; commonly used in high-cost specialty drugs

**commercial insurance-**  Coverage for medical or prescription costs provided by an employer or purchased by an individual; also called private insurance.

**coordination of benefits (COB)-** Online billing of both a primary and secondary insurer.

**Copayment-** The amount that the patient is to pay for each prescription as determined by the insurance carrier.

**days’ supply-** The time that a given amount of prescribed medication lasts a patient until the next refill; required on drug claims submitted for online insurance billing.

**Deductible-** An amount on some insurance plans that must be paid by the insured person before the insurance company considers paying its portion of a medical or drug cost.

**donut hole-** An insurance coverage gap in Medicare Part D programs under which the patient must pay a higher portion of the cost of the medication; to be phased out by 2019.

**dual copay-** Insurance coverage in which a patient pays one copay for brand name drugs and a lower copay for generic drugs; also known as a two-tier.

**dual eligible-** A patient who has both a primary and secondary insurance plan.

**DME(durable medical equipment)-** Medically necessary, reusable equipment such as nebulizers, hospital beds, wheelchairs, and walkers that may be purchased in a community pharmacy or billed to Medicare Part B.

**first party-** The person who directly receives the benefits of a service or product and is responsible for paying for it.

**group number-** An important piece of information on the insurance card that identifies the employer sponsor of the drug insurance program.

**health insurance-** Coverage of incurred medical costs, such as physician and emergency room visits, laboratory costs, and hospitalization. 

**health savings accounts(HSAs)-** Savings accounts that can be started by patients or their employers to set aside tax-deferred money specifically for healthcare costs not covered by their insurance.

**healthcare exchange-** An online shopping tool to find insurance for the uninsured or self insured; made possible by the Affordable Care Act. 

**ICD-10 (The International Classification diseases)-** 10th revision; a coding system used by prescribers and insurance companies to offer billing codes for specific diagnoses and diseases.

**in-network providers-** Prescribers and pharmacies that have a contract with the insurance provider.

**Medicaid-** A state governmental health insurance program for low-income and disabled citizens/

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**Medicare-** health insurance primarily for patients over age 65.

**PART A -** Federally sponsored insurance plan that covers 80% of the cost of hospital stays, as well as limited coverage of skilled nursing facilities, rehabilitation, and home health care; drugs are not covered under this pain.

**PART B-** Federally sponsored insurance that partially covers the cost of outpatient doctor visit; may cover the cost of nebulizer, and ne

**PART C-** Federal- and state- sponsored insurance that covers both health and prescription insurance from the same insurance provider; also called a Medicare advantage plan; may include coverage for eye and hearing examinations, glasses, hearing aids, etc.

**PART D-**  A federal- and state- partnered insurance program that provides partial coverage of prescriptions, primarily for patients who are eligible for Medicare.

**Medigap insurance-** Private insurance coverage in addition to Medicare Part B That covers a portion of the costs for outpatient physician visits as well as laboratory and x-ray fees not covered by Medicare Part B.

**NPI( national Provider Identifier)-** The unique number assigned to the provider by the federal government to allow authorized healthcare providers to process insurance claims for pharmacy reimbursement.

**online adjudication-** real-time insurance claims processing via electronic wireless.

**out-of network providers-** Prescribers and pharmacies that do not have a contract with the insurance provider; the cost of services is generally higher.

**Patient ID number-** Identifies the primary drug insurance card holder and may identify other dependents on the policy.

**Person code-** A two- or three digit number added to the patient identification number listing family members covered by the insurance plan. 

**PBM(Pharmacy benefits manager)-** A company that administers drug benefits for many insurance companies.

**preferred drug list-** A formulary provided by an insurance company that indicates preferred prescription generic and brand name drugs and their corresponding copays.

**PPO(Preferred provider organization)-** Private practice prescriber that has signed a contract with the health insurer to provide services at a discount rate. 

**Prescription drug insurance-** Specifically covers some of the cost for medications.

**PA(Prior authorization)-** Approval for coverage of a high-cost medication or a medication not on the insurer’s approved formulary obtained after a prescriber calls the insurer to justify the use of the drug; must be obtained before the drug is dispensed by the pharmacy to be covered by the insurance.

**PCN(Processor control number)**- An important piece of information located on most drug insurance cards to identify the correct PBM in order to process a prescription claim.

**Tricare-** Government insurance program for active and retired military and their families.

**workers compensation-** Insurance provided for a patient with a medical injury from a job-related accident; also called workers’ comp or workman’s comp.