PBM Glossary Terms I-L
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!
Your PreferredChoices® member ID card provides proof of your PreferredChoices® coverage. An ID card is sent to you after we accept your enrollment form. As of your effective date, your copy of the enrollment form may be used as a temporary membership card until you receive your permanent card. Your PreferredChoices® ID card includes your member identification number, as well as your toll-free phone number to contact PreferredChoices® Member Services. If you need to request a new ID card, you may do so through our Member Services page.
Refers to the use of providers who participate in the health plan's provider network.
A traditional indemnity plan allows members flexibility in their choice of recognized health care providers for covered expenses. Members are responsible for seeking care, initiating pre-certification, paying for services rendered, and submitting claims for reimbursement of covered services. Indemnity plans traditionally have out of pocket expenses such as deductibles and coinsurance which the member must pay before any expenses are paid under the plan. Benefit maximums and lifetime maximums also apply to the plan.
Independent Practice Association (IPA)
A legal entity or other group of providers that contract with managed care plans while maintaining their separate practice. A member who selects an IPA-affiliated primary care office generally will be referred to specialists and hospitals affiliated with the IPA, unless the member's medical needs extend beyond the capability of these providers.
Treatment accomplished by placing therapeutic agents into the vein, including intravenous feeding. Such therapy also includes enteral nutrition which is the delivery of nutrients into the gastrointestinal tract by tube.
Service provided after the patient is admitted to the hospital. Inpatient care lasts 24 hours or more.
A cap on the benefits paid under a policy. Many policies have a lifetime limit of $1 million, which means that the insurer agrees to cover up to $1 million in covered services over the life of the policy.