PBM Glossary Terms A-B
Appro-Rx helps improve the way pharmacy benefits management is done every day to help lower prescription costs. However, we understand that the world of PBMs can be confusing. Below we have answered your most frequently asked questions to give you a better understanding of your needs!
Adjudication
The process used by health plans to determine the availability of benefits for a claim.
Aggregate Deductible
The amount You and Your Dependents must pay for Covered Services including Prescription Drugs within a calendar year, before any benefits will be paid by the Plan. If You have single coverage (self only), the single Deductible is the amount You must pay. If You have family coverage (two or more covered family members), the family Deductible is the total amount any one or more covered family members must pay.
Allowable Expense(s)
Any Medically Necessary health expense, part or all of which is covered under any of the plans covering the Member for whom claim is made. A health care service or expense including deductibles, coinsurance or Copayments that is covered in full or in part by any of the plans covering the Member. This means that an expense or service or a portion of an expense or service that is not covered by any of the plans is not an Allowable Expense. Plan documents will show examples of expenses or services that are or are not allowable.
Ambulatory Surgery
Surgical procedures performed that do not require an overnight hospital say. Also see Outpatient Surgery.
Appeals
A process used by a member to request the health plan re-consider a previous authorization or claim decision.
Authorization
Certain healthcare services, such as hospitalization or outpatient surgery, require pre-certification with Paramount to ensure coverage for those services. When a member is to obtain services requiring pre-certification through a participating provider, this provider should pre-certify those services prior to treatment. If your plan covers self-referred services to network providers or out of-network benefits and you may self-refer for covered benefits, it is your responsibility to contact Paramount PreferredChoices® to pre-certify those services which require pre-certification to avoid a reduction in benefits paid for that service.
Benefit Period
The maximum length of time for which benefits will be paid.
Benefits
Payment received for covered services under the terms of the policy.
Brand Name Drug
A prescription drug that is protected by trademark registration.
