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PBM Glossary Terms H

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!

Health Benefit Plan

The health insurance or HMO product offered by a licensed health benefits company that is defined by the benefit contract and represents a set of covered services or expenses accessible through a provider network, if applicable, or direct access to licensed providers and facilities.

Health Insurance Portability and Accountability Act (HIPAA)

HIPAA is a federal law enacted in 1996. It was designated to improve availability and portability of health coverage by:


  • limiting exclusions for pre-existing conditions;
  • providing credit for prior health coverage;
  • allowing transmittal of the coverage information (i.e., covered family members and coverage period) to a new
  • insurer;
  • providing new rights to allow individuals to enroll for health coverage when they lose their health coverage or have
  • a new dependent;
  • prohibiting discrimination in enrollment/premiums
  • guaranteeing availability of health insurance coverage for small employers.


HIPAA's Administrative Simplification and Privacy (AS&P) Act final rules took effect in April 2001. The purpose of these rules is to
improve the efficiency of the health care system by standardizing the electronic exchange of health information and protecting the security and privacy of member-identifiable health information.

Health Maintenance Organization (HMO)

A third party legal entity which arranges payment for the provision of basic and supplemental health services to its members from a network of independently contracted providers and facilities on a prepaid or reduced fee basis. For most plans, members are required to select a network primary care physician to provide routine care and provide referrals for hospital services when appropriate. Some Paramount HMO plans do not require the member to select a PCP or obtain referrals and members can self refer for covered services within the network. Some PreferredChoices® plans provide coverage for services from out-of-network providers.

Health Reimbursement Account (HRA)

A Health Reimbursement Account (HRA) is an employer-sponsored benefit program under which employees may receive reimbursement for medical expenses. An HRA may be offered in conjunction with a high-deductible OR other type of health plan - an HDHP is not required. Under an HRA plan, the employer reimburses the employee for qualified medical care expenses. The HRA provides reimbursement up to the maximum dollar amount established by the employer group for the coverage period and  any unused portion may be carried forward to the next coverage period – as defined by the employer.

Health Risk Appraisal/Assessment (HRA)

A Health Risk Assessment (HRiskA) is a tool used to evaluate the health of a given member.   

Health Savings Account (HSA)

A Health Savings Account (HSA) is a special tax-sheltered savings account that is similar to a traditional Individual Retirement Account (IRA), but designated for medical expenses. An HSA allows you to pay for current health expenses and save for future qualified medical and retiree health care expenses on a tax-free basis. Contributions, earnings, and qualified distributions all are exempt from federal income and Social Security (FICA) taxes.

Home Health Care

Skilled nursing and other therapeutic services provided by a home health care agency in a home setting as an alternative to confinement in a hospital or skilled nursing facility

Home Infusion Therapy

The administration of intravenous drug therapy in the home.  

Hospice Care

This is palliative and supportive care, either on an inpatient or outpatient basis, given to a terminally ill person and to his or her family. The focus of hospice programs is to enable terminally ill patients to remain, for as long as they can, in the familiar surroundings of their home.


An institution rendering inpatient and outpatient services, accredited as a Hospital by the Joint Commission on Accreditation of Health Care Organizations, or as otherwise determined by Paramount as meeting reasonable standards. A hospital may be a general, acute care, rehabilitation or specialty institution.
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