A    B   C   D   E   F   G   H   I   J    K    L   M   N   O   P   Q   R   S   T   U   V   W    X    Y    Z   

A

Acute Refers to short-term illness or symptoms.

ADR Adverse Drug Reaction.

Adverse Event A toxic reaction to a medical therapy.

AWP An acronym which stands for average wholesale price.


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B

Beneficiary An individual who is eligible to use health insurance benefits.

Biotechnology Medications Medications genetically engineered from replicas of bodily substances (e.g., protein).

Brand Name Medication A medication usually under patent or has a trademarked name that appears on the package label.


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C

Capitation A reimbursement system in which healthcare providers receive a fixed fee for every patient served, regardless of how many or how few services the patient uses.

Claim A formal demand for payment or reimbursement of expenses covered under an insurance policy.

Clinical Refers to physical signs and symptoms directly observable in the human body.

Closed Formulary Plan A type of plan where pharmacy benefits do not cover medications on the Formulary Exclusions List unless the member’s doctor obtains a medical exception.

Coinsurance A type of insurance copayment where the participant’s share of payment is based on a percentage of total cost.

Compliance Adherence by a patient to a specific treatment regimen.

Cost Containment The process by which companies implement new programs or modify existing programs to continuously monitor appropriateness and cost of treatment.

Copay The copay or copayment is the amount that a participant’s share of payment to receive a covered service or product.


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D

Deductible A specified dollar amount that the participant must reach before the insurer begins payment on behalf of the participant.

Drug Benefit A benefit that allows prescription medicine to be obtained at a discounted or co-payment basis.

Diagnosis The identification of a disease or condition through analysis and examination by a physician.


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E

Efficacy Effectiveness of a medication.

Eligibility Period Describes the time during which potential members of a health insurance plan can enroll. Also can be a period under a major medical policy when reimbursable expenses can be accrued. Eligibility requirements are guidelines outlined by insurance companies to determine which individuals can be covered under a group insurance plan.

Enrollment The process allowing eligible participants to elect to be included in a benefit.

Enteral Medications that are administered into the rectum (e.g. suppository) and absorbed by the lower digestive tract.


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F

Fee-For-Service The traditional method for financing healthcare in which a provider is paid for each service rendered.

First-Line-Treatment The preferred therapy for a particular condition.

Formulary A specific set of medications chosen by hospitals, managed care organizations, insurers or state Medicaid programs as those routinely available to patients under a specific program.


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G

Generic Medication A commonly used term to identify non-brand name medications that are sold. Typically, a generic medication is a pharmaceutical equivalent to a branded medication product and has identical strength, dosage form, and concentration.


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H


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I

Intracardiac An intracardiac (IC) medication is given by needle into the heart.

Intradermal An intradermal (ID) medication is given by needle into the skin.

Intramuscular (IM) An intramuscular (IM) medication is given by needle into the muscle.

Intraperitoneal An intraperitoneal (IP) medication is given by needle into the abdominal cavity.

Intrarterial An intrarterial (IA) medication is given by needle into an artery.

Intravenous An intravenous (IV) medication is given by needle into a vein.

Injectable Medications Medications that are injected into the body. Injectable medications may be covered as a pharmacy or medical benefit, depending on the medication and health plan.


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J


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K


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L

Legend Medication A medication that requires a prescription in order to obtain it.

Limited Distribution Product A medication that can only be obtained through pharmacies determined per the FDA or manufacturer for distribution.


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M

Maintenance Medication A medication defined as needed on an ongoing basis, does not have a high instance of side effects or need of dose changes, and is used to treat a disease or condition that is non-curable.

Maximum This is the maximum dollar amount that a member is responsible per prescription, any amount over the maximum dollar amount the health plan will cover.

Medication Interactions Incidents that occur in the body when a medication is affected by another substance, such as another medication.

Medication Regimen The approved directions for when and how to take a specific medication.

Member A person who is enrolled and eligible to receive benefits under a plan. A member can also be referred to as "insured", "covered member", “participant” or "plan member".

Member ID This number is assigned to serve as the identification number for the member.

Minimum This is a minimum dollar amount that a member is responsible for before the health plan assumes any of the cost. This minimum amount applies to generic, brand formulary and brand non-formulary medications.

Mucosal Medications that are administered via the nasal mucosa, or bronchioles through inhalation of an aerosol. Vaginal administration of a medication is also considered mucosal.


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N

Networks A group of pharmacies, physicians or other healthcare providers that have agreed to provide services to insured members, usually at set price levels.


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O

Open Formulary Plan A type of plan where pharmacy benefits cover medications on the Preferred Medication List as well as other medications not listed.

Oral Medications are taken by mouth (in pill, capsule or liquid form) and absorbed into the system through the digestive system. Absorption is slow and cannot be used if vomiting is occurring.

OTC Over The Counter indicates pharmaceutical products or medications that do not require a prescription.

Out-of-Pocket Costs The portion of payments for health services that must be paid by the enrollee, including co-payments, co-insurance, or deductibles.

Out-of-Pocket Maximum The maximum amount which a covered person must pay for deductibles, coinsurance and co-pays in a defined time period (generally calendar year) before the health plan covers all remaining prescription medications at 100%.


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P

Percutaneous Medications that are absorbed directly through the skin to the blood stream.

Parenteral Parenteral refers to any medication administration that involves injecting a drug directly into a vein (intravenous), muscle (intramuscular), artery (intrarterial), abdominal cavity (intrperitoneal), heart (intracardiac) or into the fatty tissue beneath the skin (subcutaneous). The speed of absorption varies, but is faster than oral administration and is used when more complete and faster absorption is needed.

Pharmacy & Therapeutics (P&T) Committee A panel of independent physicians and pharmacists that evaluates all available research on a medication before adding it to an approved formulary list. The committee continually reviews and updates the formulary and also determines what medications have a Prior Authorization (PA) or Quantity Limit (QL) status. Members maintain strict confidence on formulary discussions to prevent influence from outside sources.

Payer The party that pays for covered benefits on behalf of the plan sponsor and the plan sponsor’s members. This is sometimes referred to as a "third party payer".

PBM (Prescription Benefit Manager) PBM's are companies that administer and manage the prescription benefit for health plan sponsors.

Pharmacy Network A group of pharmacies identified as having contractually agreed to provide prescription medications to plan participants at specified discounts or rates.

Plan Sponsor The company or organization that assumes financial responsibility for an insured group.

Prescribed Medication A medication which has been prescribed by an authorized physician for a patient.

Prior Authorization (PA) Process that monitors the use of medications most likely to have certain risk factors. In order to obtain a medication that requires a PA, certain criteria must be met before the plan will pay for the medication or treatment.


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Q

Quantity Limits (QL) Assigned to medications that are frequently taken in an inappropriate manner or used in amounts that exceed recommendations for dosage or length of treatment. Limits are based on Federal Medication Administration (FDA) and pharmaceutical manufacturer recommendations.


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R

Renewal The term used when a prescription has exhausted all of its refills and requires the physician to write a new prescription. This is considered renewing a prescription.


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S

Side Effects Any unwanted physical or mental states caused as a result of using a medication; also called an "adverse effect."

Step Therapy A process treatment encourages utilization of select medication(s) before other medication(s) are used due to cost, safety and medical appropriateness.

Subcutaneous With a subcutaneous injection, a needle is inserted just under the skin. A drug (i.e. insulin) can then be delivered into the subcutaneous tissues. After the injection, the drug moves into small blood vessels and the bloodstream. The subcutaneous route is used with many protein and polypeptide drugs such as insulin which, if given by mouth, would be broken down and digested in the intestinal tract.


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T


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U

Utilization Review Process in which either an internal or external agency reviews patterns of utilization against normal or policies established by the organization or set by health plans.


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V


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W


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X


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Y


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Z


A    B   C   D   E   F   G   H   I   J    K    L   M   N   O   P   Q   R   S   T   U   V   W    X    Y    Z   

A

Acute Refers to short-term illness or symptoms.

ADR Adverse Drug Reaction.

Adverse Event A toxic reaction to a medical therapy.

AWP An acronym which stands for average wholesale price.


(return to top)


B

Beneficiary An individual who is eligible to use health insurance benefits.

Biotechnology Medications Medications genetically engineered from replicas of bodily substances (e.g., protein).

Brand Name Medication A medication usually under patent or has a trademarked name that appears on the package label.


(return to top)


C

Capitation A reimbursement system in which healthcare providers receive a fixed fee for every patient served, regardless of how many or how few services the patient uses.

Claim A formal demand for payment or reimbursement of expenses covered under an insurance policy.

Clinical Refers to physical signs and symptoms directly observable in the human body.

Closed Formulary Plan A type of plan where pharmacy benefits do not cover medications on the Formulary Exclusions List unless the member’s doctor obtains a medical exception.

Coinsurance A type of insurance copayment where the participant’s share of payment is based on a percentage of total cost.

Compliance Adherence by a patient to a specific treatment regimen.

Cost Containment The process by which companies implement new programs or modify existing programs to continuously monitor appropriateness and cost of treatment.

Copay The copay or copayment is the amount that a participant’s share of payment to receive a covered service or product.


(return to top)


D

Deductible A specified dollar amount that the participant must reach before the insurer begins payment on behalf of the participant.

Drug Benefit A benefit that allows prescription medicine to be obtained at a discounted or co-payment basis.

Diagnosis The identification of a disease or condition through analysis and examination by a physician.


(return to top)


E

Efficacy Effectiveness of a medication.

Eligibility Period Describes the time during which potential members of a health insurance plan can enroll. Also can be a period under a major medical policy when reimbursable expenses can be accrued. Eligibility requirements are guidelines outlined by insurance companies to determine which individuals can be covered under a group insurance plan.

Enrollment The process allowing eligible participants to elect to be included in a benefit.

Enteral Medications that are administered into the rectum (e.g. suppository) and absorbed by the lower digestive tract.


(return to top)


F

Fee-For-Service The traditional method for financing healthcare in which a provider is paid for each service rendered.

First-Line-Treatment The preferred therapy for a particular condition.

Formulary A specific set of medications chosen by hospitals, managed care organizations, insurers or state Medicaid programs as those routinely available to patients under a specific program.


(return to top)


G

Generic Medication A commonly used term to identify non-brand name medications that are sold. Typically, a generic medication is a pharmaceutical equivalent to a branded medication product and has identical strength, dosage form, and concentration.


(return to top)


H


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I

Intracardiac An intracardiac (IC) medication is given by needle into the heart.

Intradermal An intradermal (ID) medication is given by needle into the skin.

Intramuscular (IM) An intramuscular (IM) medication is given by needle into the muscle.

Intraperitoneal An intraperitoneal (IP) medication is given by needle into the abdominal cavity.

Intrarterial An intrarterial (IA) medication is given by needle into an artery.

Intravenous An intravenous (IV) medication is given by needle into a vein.

Injectable Medications Medications that are injected into the body. Injectable medications may be covered as a pharmacy or medical benefit, depending on the medication and health plan.


(return to top)


J


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K


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L

Legend Medication A medication that requires a prescription in order to obtain it.

Limited Distribution Product A medication that can only be obtained through pharmacies determined per the FDA or manufacturer for distribution.


(return to top)


M

Maintenance Medication A medication defined as needed on an ongoing basis, does not have a high instance of side effects or need of dose changes, and is used to treat a disease or condition that is non-curable.

Maximum This is the maximum dollar amount that a member is responsible per prescription, any amount over the maximum dollar amount the health plan will cover.

Medication Interactions Incidents that occur in the body when a medication is affected by another substance, such as another medication.

Medication Regimen The approved directions for when and how to take a specific medication.

Member A person who is enrolled and eligible to receive benefits under a plan. A member can also be referred to as "insured", "covered member", “participant” or "plan member".

Member ID This number is assigned to serve as the identification number for the member.

Minimum This is a minimum dollar amount that a member is responsible for before the health plan assumes any of the cost. This minimum amount applies to generic, brand formulary and brand non-formulary medications.

Mucosal Medications that are administered via the nasal mucosa, or bronchioles through inhalation of an aerosol. Vaginal administration of a medication is also considered mucosal.


(return to top)


N

Networks A group of pharmacies, physicians or other healthcare providers that have agreed to provide services to insured members, usually at set price levels.


(return to top)


O

Open Formulary Plan A type of plan where pharmacy benefits cover medications on the Preferred Medication List as well as other medications not listed.

Oral Medications are taken by mouth (in pill, capsule or liquid form) and absorbed into the system through the digestive system. Absorption is slow and cannot be used if vomiting is occurring.

OTC Over The Counter indicates pharmaceutical products or medications that do not require a prescription.

Out-of-Pocket Costs The portion of payments for health services that must be paid by the enrollee, including co-payments, co-insurance, or deductibles.

Out-of-Pocket Maximum The maximum amount which a covered person must pay for deductibles, coinsurance and co-pays in a defined time period (generally calendar year) before the health plan covers all remaining prescription medications at 100%.


(return to top)


P

Percutaneous Medications that are absorbed directly through the skin to the blood stream.

Parenteral Parenteral refers to any medication administration that involves injecting a drug directly into a vein (intravenous), muscle (intramuscular), artery (intrarterial), abdominal cavity (intrperitoneal), heart (intracardiac) or into the fatty tissue beneath the skin (subcutaneous). The speed of absorption varies, but is faster than oral administration and is used when more complete and faster absorption is needed.

Pharmacy & Therapeutics (P&T) Committee A panel of independent physicians and pharmacists that evaluates all available research on a medication before adding it to an approved formulary list. The committee continually reviews and updates the formulary and also determines what medications have a Prior Authorization (PA) or Quantity Limit (QL) status. Members maintain strict confidence on formulary discussions to prevent influence from outside sources.

Payer The party that pays for covered benefits on behalf of the plan sponsor and the plan sponsor’s members. This is sometimes referred to as a "third party payer".

PBM (Prescription Benefit Manager) PBM's are companies that administer and manage the prescription benefit for health plan sponsors.

Pharmacy Network A group of pharmacies identified as having contractually agreed to provide prescription medications to plan participants at specified discounts or rates.

Plan Sponsor The company or organization that assumes financial responsibility for an insured group.

Prescribed Medication A medication which has been prescribed by an authorized physician for a patient.

Prior Authorization (PA) Process that monitors the use of medications most likely to have certain risk factors. In order to obtain a medication that requires a PA, certain criteria must be met before the plan will pay for the medication or treatment.


(return to top)


Q

Quantity Limits (QL) Assigned to medications that are frequently taken in an inappropriate manner or used in amounts that exceed recommendations for dosage or length of treatment. Limits are based on Federal Medication Administration (FDA) and pharmaceutical manufacturer recommendations.


(return to top)


R

Renewal The term used when a prescription has exhausted all of its refills and requires the physician to write a new prescription. This is considered renewing a prescription.


(return to top)


S

Side Effects Any unwanted physical or mental states caused as a result of using a medication; also called an "adverse effect."

Step Therapy A process treatment encourages utilization of select medication(s) before other medication(s) are used due to cost, safety and medical appropriateness.

Subcutaneous With a subcutaneous injection, a needle is inserted just under the skin. A drug (i.e. insulin) can then be delivered into the subcutaneous tissues. After the injection, the drug moves into small blood vessels and the bloodstream. The subcutaneous route is used with many protein and polypeptide drugs such as insulin which, if given by mouth, would be broken down and digested in the intestinal tract.


(return to top)


T


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U

Utilization Review Process in which either an internal or external agency reviews patterns of utilization against normal or policies established by the organization or set by health plans.


(return to top)


V


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W


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X


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Y


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Z



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