PBM GLossary Terms P
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!
Any physician, hospital, skilled nursing facility, or other individual or entity involved in the delivery of health care or ancillary services which contracts to provide Covered Services to Members for a negotiated charge. Also called Preferred Care Provider.
Treatment involving physical movement to relieve pain, restore function and prevent disability following disease, injury, or loss of limb.
Plan documents include the Group Agreement, Group Policy, and Certificate or Evidence of Coverage (or Certificate of Insurance).
A point of service plan provides benefits for covered services received from both participating and non-participating providers. When you enroll in a point-of-service plan, you choose a primary care physician (PCP) for yourself and each covered dependent. In order to minimize your out of pocket expenses, you must access care through your PCP, except for emergency care or direct access benefits. You are responsible for a copayment, or coinsurance. Participating/preferred providers will pre-certify all necessary services and may not balance bill you. Care received on a self-referred or non-preferred basis will subject you to higher out of pocket costs such as deductibles, coinsurance and balance billing. You are also responsible for obtaining pre-certification for services provided by non-network providers.
A health condition (other than a pregnancy) or medical problem that was diagnosed or treated during a specified timeframe prior to enrollment in a new health plan. Some pre-existing conditions may be excluded from coverage during a specified timeframe after the effective date of coverage in a new health plan. Plan documents will provide specific information on pre-existing conditions.
Preauthorization / Pre-certification
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 outof-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.
Preferred Provider Organization (PreferredChoices)
Paramount's preferred provider organization (PPO) plan is called PreferredChoices®. Members may choose any licensed health care providers for covered expenses; however, they will have lower out of pocket expenses when they utilize participating
An order of a prescriber for a prescription drug. If it is an oral order, it must promptly be put in writing by the pharmacy.
Primary Care Physician (PCP)
A Participating Physician who supervises, coordinates and provides initial care and basic medical services as a general or family care practitioner, or in some cases, as an internist or a pediatrician to members, and maintains continuity of patient care.
A device that replaces all or a portion of a part of the human body. These devices are necessary because a part of the body is permanently damaged, is absent, or is malfunctioning.
A licensed health care facility, program, agency, physician, or health professional that delivers health care services.
Physicians, hospitals and other health care providers who contract with Paramount to participate in health benefits plans. For certain PreferredChoices® plans, a member must access care through the network to receive the maximum level of benefits Also Network