Glossary

For many of our patients, understanding insurance and pharmacy jargon can be a challenge. This glossary was designed to help you make sense of some of the technical terms used by insurance providers and pharmacies.

Insurance30 terms

Adjudicate

The action of processing a claim through the insurance provider. The terms “process” or “run” are interchangeable with “adjudicate.”

Benefits Investigation

A look into a patient’s health plan to determine the extent to which medication is covered by insurance.

Coinsurance

The amount patients pay for medical care after meeting their deductible. The amount is usually given as a percentage; for example, if a patient’s health plan covers 90 percent of expenses, the patient pays a coinsurance of 10 percent.

Copay

A flat fee paid every time a patient receives medical care or fills a prescription.

Deductible

The dollar amount patients must pay each year before their health plan begins covering health care costs.

Detailed Written Order

A document required when billing to Medicare and Medicaid for medical equipment, including prosthetics, orthotics, and supplies. A detailed written order must be signed by the prescriber and sent to the supplier before submitting a claim to Medicare or Medicaid.

Fee for Service

Traditional health insurance model in which both patients and their plan contribute to health care payments after yearly deductibles have been met. Usually, patients have their choice of physician, provider, or hospital.

Formulary

An official list of specific medications that are covered by a health plan.

Funding

Assistance for copayments or the full cost of a drug.

Health Maintenance Organization (HMO)

Managed care organization requiring patients to receive treatment from participating providers. Patients must obtain a referral from their primary care physician before seeing a specialist.

Exclusions

Services not covered by a patient’s insurance plan.

Letter of Medical Necessity

A legal document that explains a physician’s rationale for prescribing a specific therapy for a patient, including why a substitute treatment is inappropriate.

Limited-Distribution Drug

Specialty medication only available through specialty pharmacies, designed to treat complex and chronic disease states.

Lifetime Maximum

The total dollar amount paid by a plan for coverage while the insured person is alive and covered.

Medicaid

A social health care program supported by the federal government that provides insurance for people of all ages whose income is insufficient to cover their medical needs. Specific eligibility and features vary from state to state.

Medicare

A social health care program supported by the federal government that provides insurance for individuals age 65 and older, certain younger people with disabilities, and people suffering from permanent kidney failure.

Medicare A

Inpatient care under Medicare — specifically the care a patient receives in the hospital, at a skilled nursing facility, or through home health care.

Medicare B

Outpatient care under Medicare — specifically physician services, home health care, durable medical equipment, certain outpatient drugs, and clinical laboratory services.

Medicare D

A program that subsidizes the costs of prescription drugs and prescription drug insurance premiums for Medicare beneficiaries (also known as Medicare’s prescription drug benefit).

Medigap

Extended health insurance purchased from private companies to cover costs not covered by Medicare, such as copays, deductibles, and out-of-country coverage. This does not include long-term care, dental insurance, or vision insurance.

Open Enrollment

A set time period (usually at the end of the year) during which participants have the ability to enroll in or change their health insurance without a qualifying event (e.g., marriage, divorce, birth or adoption, or the death of a spouse).

Out-of-Pocket Maximum

The maximum amount that insured patients are required to pay for covered medical expenses during their benefit period. Once the out-of-pocket maximum has been met, patients do not pay further deductibles or coinsurance for the rest of that year.

A successfully billed request for payment that has been covered by insurance. There may be remaining copayments.

Payor

Any party (besides the patient) that finances or reimburses treatment or health care services costs, including sponsors (employers, unions), insurance carriers, or third-party payors.

Point-of-Service Plan

A managed care plan in which primary care physicians provide patient care, and which offers patients more choice of doctors and hospitals than an HMO.

Pre-Existing Condition

Any physical or mental condition the patient had when applying for a policy that may not be covered by insurance. The condition should have already been recommended for care or treated.

Preferred Provider Organization (PPO)

Managed care organization that offers patients more choice of physicians and providers than an HMO. Patients can choose between participating and nonparticipating providers, but out-of-pocket expenses will be lower when using participating providers.

Premium

The amount paid to join a health care plan. If insurance is employer-sponsored, the premium is usually deducted from the employee’s salary.

Prior Authorization

An insurance company’s approval process, required for certain medications before a patient can receive them.

Rejection

A denial that outlines the reasons insurance will not cover medication. There are several reasons for a rejection, including the patient exceeding their plan limitations, filling their prescriptions too early, or not receiving a prior authorization.

Adherence

Taking medication correctly, as prescribed by the patient’s doctor.

Date of Order

The date an order is written, which may differ from the start date of the medication cycle.

Dispense

To supply or deliver prescription medicine.

Injectable

Prescriptions that can be injected. For more information on administering home injections, please review our how-to guides in Community Resources.

Medpak

Clear plastic pouches that provide patients with a convenient way to organize and schedule medication.

Need-By Date

The date a new round of medication must be supplied.

Oncology

The study and treatment of cancer.

Prescribing Physician

The doctor that sets a patient’s specific medication requirements.

Prescription

The medicine or care plan ordered by a doctor.

Side Effect

Unwanted issues or illnesses that may occur during therapy. Some side effects can have the positive effect of indicating that a treatment is proceeding successfully. For more information on dealing with side effects, please review our how-to guides in Community Resources.

Specialty Pharmacy

Pharmacies that offer intensive therapies for complex disease states. All Vivo Health Pharmacy locations are specialty pharmacies dealing with serious health conditions and disease states including cancer, hepatitis C, HIV-AIDS, multiple sclerosis, transplant, rheumatoid arthritis, and more.

Start Date

The designated first day of patient treatment.

Starter Kit

The tools provided to patients to help counter possible side effects of their treatment. Starter kit items can include creams and over-the-counter pain relief medications. Medication manufacturers sometimes provide medication starter kits. In this instance, the starter kit provides patients with a specific drug and dosing regimen designed to help them through the first days of therapy.

Step Therapy

A process that involves trying alternate — usually cheaper — medications before “stepping up” to drugs that cost more.