Understanding Complex Terms

The specific outline of coverage provided by insurance plans that dictates what is covered and what is not.

Drugs sold under a proprietary, trademark-protected name.

The fixed amount a patient pays for a covered health care service, usually when receiving the service.

Programs designed to help patients cover the cost of medications in terms of copays, coinsurance, and deductibles.

A period in a Medicare drug plan where there is a temporary limit on what the drug plan will cover for drugs.

The amount you pay for covered health services before your insurance plan starts to pay.

The categorization of prescription drugs on how much they cost within a particular drug benefit plan.

A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits.

Drugs that are chemically identical to their branded counterparts but generally sell for lower prices.

A pharmacy service that offers the convenience of sending prescriptions directly to the patient's home.

The maximum amount a consumer must pay out-of-pocket within a year for covered expenses under a health insurance plan.

A PBM manages prescription drug benefits on behalf of health insurers, Medicare Part D drug plans, large employers, and other payers.

The branch of health economics that assesses the cost and effects of pharmaceutical products.

A network of pharmacies where prescriptions may be filled for members of a specific insurer or health plan.

The amount that must be paid for your health insurance or plan.

A requirement that a provider obtain approval from a health plan before it will cover a specific medication.

The management of discounts or returns secured from pharmaceutical manufacturers which may or may not be shared with plan members.

A pharmacy that dispenses high-cost and high-complexity medications used to treat rare, chronic, or complex conditions.

A type of utilization control that requires a specific sequence of therapy before a drug will be covered.

The practice of substituting a drug that is chemically different but therapeutically similar to the drug originally prescribed.