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PBM Self-Insuring Questions

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!

What do I need to know about Administrative Services?

These services include medical review, processing and payment of claims, processing of employee applications, maintenance of membership files, conversion plans for terminating employees, assistance in the development and preparation of Summary Plan Description, distribution of identification cards, and completion of actuarial and statistical reports.

What is aggregate Stop-Loss?

The maximum level of claims payment for which the Self-Funded employer has liability. Claims in excess of this level are reimbursed by the Stop-Loss carrier. Such a plan is set for the contract year based on a percentage of expected claims during the contract period.

What is the aggregate Stop-Loss attachment point?

The total dollar amount of paid or incurred benefits for all members per contract period, beyond which the insurance carrier will reimburse you, up to the maximum reimbursement.

What is immediate Stop-Loss protection?

Coverage that begins immediately once the Individual Stop-Loss has been reached. This limits the employer’s maximum claims responsibility for an Individual that has claims exceeding the Individual Stop-Loss.

What is individual stop-loss?

The dollar amount per individual per contract year which is the employer’s responsibility. Also referred to as Specific Stop-Loss.

What is stop-loss insurance?

A supplemental protection plan employers may purchase to establish a cap on their claims responsibility. Provides protection against catastrophic or unpredictable losses.

What are covered charges?

Charges for medical care or supplies which, if incurred by a participant or other covered person, create a liability for the insurer under the terms of a group policy.

What is a claims administrator?

A company appointed by the employer to handle all administrative duties including the processing and paying of claims from the employer’s designated account.

What is incurred contract?

A self-funded contract based on the date in which claims are incurred by the eligible members.

What is claims experience?

Past claims utilization for an employer group.

What is paid claims basis?

Individual and Aggregate Stop-Loss is based on the date the claim is paid.

What is a paid contract?

A self-funded contract based on the date in which claims are paid on behalf of the eligible members.

What is a risk corridor?

The difference between expected claims and the Aggregate Stop-Loss Attachment Point. This is the risk the employer is accepting in the Self-Funded plan.

What is coordination of benefits?

A method of integrating benefits payable under more than one group health benefit plan.

What is a suggested funding level?

The recommended dollar amount you should set aside per contract, per month, to adequately

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