PBM Glossary Terms O
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!
Treatment to restore a physically disabled person's ability to perform activities such as walking, eating, drinking, dressing, toileting, and bathing.
The use of health care providers who have not contracted with the health plan to provide services. Members enrolled in preferred provider organizations (PPO) and point-of-service (POS) coverages can go out-of-network for covered expenses, but will pay additional costs in the form of deductibles and coinsurance and will be subject to benefit and lifetime maximums. Because reduced fees are not negotiated with out-of-network providers, Paramount will calculate reimbursement based on the usual, customary and reasonable charge, (see definition). Members are responsible for all charges above UCR in addition to any deductible and coinsurance provisions.
The maximum out of pocket amount that an enrollee will have to pay for expenses covered under the health plan. The maximum may be a coinsurance maximum or a copayment maximum. Generally the out of pocket maximum is calculated by the sum of all paid deductible and copayment or coinsurance amounts. Some POS plans may have two types of out of pocket maximums, and the member is required to meet both maximums before the plan pays expenses 100%. Once member reaches the out of pocket maximum(s), the plan pays 100% of expenses for covered services.
Care provided in a clinic, emergency room, hospital or non-hospital surgical facility ("SurgiCenter") without admission to the hospital or facility.
Surgical procedures performed that do not require an overnight stay in the hospital or ambulatory surgery facility. Such surgery can be performed in the hospital, a surgery center, or physician office. Also see Ambulatory Surgery.