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Prime Dictionary

A

Abridged formulary

A shorter list of medicines that your pharmacy plan covers. It shows only the most commonly prescribed drugs.

Accumulated deductible

The amount that you and any other family members pay towards your plan deductible during the plan year.

Amount due

The amount that you pay the pharmacy (after plan discounts) for your prescription.

B

Benefit

This word can mean more than one thing:

  • Your medical or pharmacy insurance coverage
  • Products and services that are covered by your medical or pharmacy plan
  • Payments made by your medical or pharmacy plan for covered products or services.

Benefit design

The details of your pharmacy coverage, including copays, deductibles, drug exclusions, number of days supply and any benefit exclusions.

Benefit exclusion

Some pharmacy benefit plans may not cover all prescription drugs, services or supplies. This is called a benefit exclusion. You may also hear it called a plan exclusion.

Benefit limitation

Any limit that is applied to your benefit plan. For example, you may be limited to a 30-day supply of a medicine for each refill or a three-refill limit at a retail pharmacy.

Benefit maximum

The maximum amount that the plan will pay for each member. This is sometimes called a lifetime maximum. If you reach the benefit maximum, you would have to pay 100% of your prescription medicine costs, out-of-pocket.

Benefit plan

Our benefit plan includes coverage for medical and pharmacy expenses. If you get your benefits through your employer, your benefit plan could include life, dental or disability insurance; it depends on the specific benefit plan design. Prime Therapeutics manages the pharmacy portion of your benefit plan, processes claims, and offers services like home delivery pharmacy through PrimeMail®.

Brand-name drug or brand prescription drug

A medicine that is manufactured and sold by a pharmaceutical company that holds a patent on the actual drug or the drug name. (For example: Lipitor® is a brand name for the cholesterol medicine atorvastatin calcium).

Brand/formulary drug

A brand-name drug that is on Prime's drug list, also called formulary. Your share of the cost of these drugs will usually be higher than for a generic drug.

Brand/non-formulary

A brand-name drug that is not on Prime's drug list (or formulary). Your share of the cost on these medicines is typically higher than brand-name medicines that are on the drug list. Sometimes, these medicines are not covered at all.

C

Chain pharmacy

One of a group of pharmacies, usually three or more, that are owned or managed by the same company.

Claim

A request for payment for products or services covered by your plan. Claims can come from you or a family member, or directly to your plan from your doctor or pharmacy.

Closed formulary

A type of benefit design in which only medicines included on the drug list (or formulary) are covered. You may be able to get a medicine that is not on the drug list. But, you may have to pay 100% of the cost, unless a formulary exception is submitted and your health plan approves it.

Coinsurance

The percentage of the total cost that you pay for your medicines, after you've met any deductible that applies. For example, if your plan pays 80% of the cost of your medicine, then your coinsurance (the amount you would pay) is 20%.

Compliance

When a patient follows the doctor's directions for taking their medicines, or follows the treatment plan for their condition.

Copayment, copay

The amount you pay out-of-pocket for your prescription medicines. Some plans use a dollar amount (for example, $4 for generic drugs or $20 for a doctor's visit. Some plans use a percentage (for example, 15% of the total cost of a drug).

Cost share

The amount you pay out-of-pocket for your prescription medicines.

Covered person

A person who is enrolled in or covered by a benefit plan is able to use the benefits.

Covered services

The pharmacy or medical service and supplies that your benefit plan pays for.

Customer Service Center

Also called Member Services or call center. Your plan's member service represetatives work here, taking calls and answering questions about your plan, your claims and your coverage.

D

Date filled (fill date)

The date the prescription was filled, or service (for example, a flu shot), was provided.

Days supply

The number of days your prescription will last. This is sometimes based on how much of the medicine your doctor prescribes (for example, a 10-day supply). For medicine that you take every day (like blood pressure or cholesterol medicine), this generally is a 30 or 90-day supply.

Deductible

The amount of money that you and anyone covered by your plan must pay out-of-pocket each plan year for covered services before your plan starts to pay.

Dispensing limitations

A plan may limit the number of days or the number of pills supplied for each prescription. A plan may also limit certain drugs based on the age or sex of the member.

Dosage form

How the medicine is dispensed (tablet, capsule, liquid, cream, etc.).

Dose

A measured unit of your medicine that you would take at one time. For example: one pill every 8 hours, or 1 teaspoon one time per day.

Drug tier

Your plan's drug list will have different tiers, or levels of coverage, for medicines. Generally, the lower the tier, the lower the cost of the medicine.

E

Eligible person

Any person who is covered by your plan at the time a pharmacy fills his or her prescriptions.

Evidence of coverage (EOC)

A description of benefits included in your plan. Your insurance company is required by state or federal law to give you a copy of this document, or make it available to you. Some plans may send you a handbook with the same information instead of an evidence of coverage document.

Exclusions

Products or services that your benefit plan does not cover.

Extended supply (EXT)

Most retail pharmacies can only fill up to a 30-day supply of medicine. An extended supply pharmacy is able to fill up to a 90-day supply. These are usually medicines that you take every day to treat a condition like high blood pressure or cholesterol.

F

Food and Drug Administration (FDA)

The federal agency that monitors prescription drugs and reviews the drug manufacturers’ clinical testing to make sure that medicines are safe and effective. The FDA also keeps track of how drugs are manufactured and responds to reports of problems or risks.

Formulary

A list of medicines that your pharmacy plan covers depending on your benefit. This list may change during the year.

Formulary exception

A type of coverage determination request. This request would be used to get coverage for a medicine not listed on the drug list (formulary), such as when your doctor believes a non-formulary drug is best for you.

Formulary status

Which tier a medicine appears in on a drug list (formulary). For instance, the formulary status for Lipitor may be Tier 3/preferred brands.

G

Generic drug

A lower-cost version of a brand-name drug, which becomes available when the patent expires on a brand-name drug. (For example: atorvastatin calcium is the generic name for the brand-name cholesterol drug Lipitor®.) Generic drugs are chemically equal to the brand name drug, but don’t use the brand name. They are regulated by the Food and Drug Administration (FDA).

Generic/formulary

A generic drug that is on Prime's drug list (or formulary). These drugs usually have the lowest cost share, unless they are not covered. If a generic/formulary drug is not covered, you may have to pay the entire cost of the drug.

Generic/non-formulary

A generic drug that is not on Prime's drug list (or formulary). These drugs usually have the lowest cost share, unless they are not covered. If a generic/non-formulary drug is not covered, you may have to pay the entire cost of the drug.

H

Health Insurance Portability and Accountability Act (HIPAA)

HIPAA is a federal law that helps protect your private health information. You usually will get a HIPAA notice at the doctor’s office that explains how they will share your private health information.

Health Savings Account (HSA)

A tax-exempt savings account that you can use if you are covered by a high deductible health plan. You can use the money to pay for health or pharmacy services that are covered, or save for future health care expenses.

Home delivery pharmacy services

A licensed pharmacy that fills your maintenance drugs and delivers them to your home. Also called mail-order pharmacy. Home delivery pharmacy plans can save you time and money, and usually fill prescriptions for a three-month supply at a time. PrimeMail® is Prime's home delivery pharmacy.

Home Infusion Pharmacy

A pharmacy that focuses on home infusion therapy medicines and supplies.

I

Identification card

The card you get from your health or pharmacy plan with your membership information. This card confirms that you are enrolled in the plan.

In-network pharmacy

A pharmacy that is in Prime's network of over 64,000 pharmacies; also called a network pharmacy.  

*Per Geo Access analysis conducted in July 2013

Indian Health Services, Tribal and Urban Indian Health Program pharmacy

A pharmacy that serves the Indian Health Service, Tribal, and Urban Indian Health Program. Only Native Americans and Alaska Natives have access to these pharmacies through their Medicare Part D plan's pharmacy network.

L

Legend drug

A drug which cannot legally be obtained without a doctor's prescription. The original product container has the words: "Federal Law prohibits dispensing without a prescription." or "Rx Only."

Licensed prescriber

A doctor, nurse practitioner, physician's assistant or other individual who has been licensed by the state to prescribe medicine.

Long term care pharmacy

A pharmacy located in a long term care or nursing facility.

M

Mail order claim

A request for payment for products or services covered by your plan. Claims can come from you or a family member, or directly to your plan from your doctor or pharmacy.

Mail-order pharmacy

A licensed pharmacy that fills your maintenance drugs and delivers them to your home. Also called home delivery pharmacy. Home delivery pharmacy plans can save you time and money, and usually fill prescriptions for a three-month supply at a time. PrimeMail® is Prime's home delivery pharmacy.

Maintenance drug

A prescription drug that treats a chronic condition (for example: diabetes, arthritis, high blood pressure, or heart disease).

Manufacturer

A company that makes and/or distributes medicines. A manufacturer can make prescription drugs or over-the counter products.

Maximum out-of-pocket (or out-of-pocket maximum)

This is the most that you will pay in a plan year for your covered drugs or services. Once you reach this maximum, your plan may pay 100% for any covered items; this may or may not include medicines.

Maximum refills

The number of times you can refill a prescription without getting a new one from your doctor.

Medicaid

A state-run health plan for low-income and disabled people. The federal government and each state government share the costs of this program.

Medicare

A national health care plan that covers medical care and hospitalization, usually for people 65 and older. The Medicare health benefit has two main parts:

  • Part A covers inpatient hospital costs.
  • Part B covers doctor visits and outpatient costs.
  • Medicare Part D is an extra service that people who are eligible for Medicare can buy from private insurers that covers prescription drugs.

Medicare Part D

The official name of Medicare's prescription drug coverage. You can buy a Medicare Part D plan from approved private health insurers, like Blue Cross and Blue Shield.

Member(s)

Someone who is covered by a benefit plan.

Member ID

The unique number assigned to you. This number is on your ID card.

Multi-source

Generic medicines that are made and sold by two or more manufacturers.

N

Network

A group of pharmacies that have a contract with a health plan carrier or pharmacy benefit manager to provide covered products and services to members.

Non-formulary

A non-formulary medicine is not on your plan’s drug list. But, it may be covered on a temporary basis during your 90-day transition period. If you want to keep taking a non-formulary medicine, work with your prescriber to ask for a formulary exception or to switch to a different drug.

Non-preferred

A drug that may be covered by your pharmacy plan, but is not on Prime's drug list (or formulary). You may be able to purchase a non-preferred drug, but it may cost you more than a preferred drug.

Non-preferred mail order pharmacy

A licensed pharmacy that fills your maintenance drugs and delivers them to your home. A non-preferred mail order pharmacy will have a higher copay/coinsurance than a preferred mail order pharmacy, which has an agreement with your health care plan.

Not covered

Prescription drugs that are not included in your Medicare prescription drug plan. The law does not allow certain drugs to be covered through Medicare Part D.

O

Open formulary

A benefit design that covers all prescription drugs, whether they are on the drug list (or formulary) or not. Drugs that are not listed on the drug list will typically cost you more.

Out-of-network pharmacy

A pharmacy that is not in Prime's network of pharmacies. There are more than 64,000 pharmacies in Prime's network of pharmacies.

*Per Geo Access analysis conducted in July 2013.

Out-of-pocket

The portion of payments for health services required to be paid by the member, including copayments, coinsurance, cost share and deductibles.

Out-of-pocket maximum

This is the most that you will pay in a plan year for your covered drugs or services. Once you reach this maximum, your plan may pay 100% for any covered items; this may or may not include medicines.

Over-the-counter (OTC)

A medicine that you can buy without a prescription from your doctor.

P

Paper claim

A request for payment for a covered product or service that you paid for when you received it. You submit the paper claim to your plan yourself.

Pharmaceutical equivalents

Medicines that have identical amounts of the same active ingredients. They have the same dosage form (tablets, capusules, etc). These medicines are usually generic, and meet the FDA's standards for strength, quality and purity.

Pharmacy benefit manager (PBM)

A company, like Prime Therapeutics, that manages prescription drug benefits for a health plan.

Pharmacy network

A group of pharmacies that have contracted with a health plan or pharmacy benefit manager to provide covered products and services to members.

Pharmacy types

A pharmacy is licensed to prepare, dispense and sell medicines. There are several types of pharmacies, including:

  • Network pharmacy: A pharmacy that has a contract with a health plan or pharmacy benefit manager to provide covered products and services to members.
  • Retail Pharmacy: A pharmacy located in a retail store intead of a hospital or clinic.
    Retail Pharmacy with Extended Supply: A retail pharmacy where your plan lets you buy up to a 90-day supply of a long-term medicine. Most retail pharmacies can only fill up to a 30-day supply of medicine. 
  • Mail Order Pharmacy: A licensed pharmacy that fills your maintenance drugs and delivers them to your home. Also called a home delivery pharmacy. Home delivery pharmacy plans can save you time and money, and usually fill prescriptions for a three-month supply at a time. PrimeMail® is Prime's home delivery pharmacy.
    Home Infusion Pharmacy: A pharmacy that focuses on home infusion therapy medicines and supplies. 
  • Long Term Care Pharmacy: A pharmacy located in a long term Care or nursing facility. 
  • I/T/U: An I/T/U pharmacy serves the Indian Health Service, Tribal, and Urban Indian Health Program.

Plan exclusion

Some pharmacy benefit plans may not cover all prescription drugs, services or supplies. This is called a plan exclusion. You may also hear it called a benefit exclusion.

Plan paid amount

The amount that your plan pays to your doctor, pharmacy or you. You pay any remaining balance, which could include your copay, coinsurance, cost share or deductible.

Preferred drug

A drug that is included on your plan's drug list (also called a formulary). Sometimes, several drugs can treat the same condition, and your benefit plan may choose some drugs over others. Benefit plans typically cover more of the cost of preferred drugs than they do of non-preferred drugs.

Preferred mail order pharmacy

A licensed pharmacy that fills your maintenance drugs and delivers them to your home. A preferred mail order pharmacy has a contract with your health care plan, and will have a lower copay/coinsurance than a non-preferred mail order pharmacy.

Preferred pharmacy

If your health plan's pharmacy network includes "preferred pharmacies," you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred pharmacy. If your health plan's pharmacy network includes preferred pharmacies, you can filter by preferred pharmacies within the pharmacy search feature of MyPrime.com to compare cost estimates.

Premium

The amount you pay each month for your health insurance.

Prescribers

Health care professionals who are licensed by their state to prescribe medicines, for example: doctors, nurse practitioners, physician assistants and dentists.

Prescription drug benefit

Your prescription drug benefit is the method of reimbursing members or pharmacies for the cost of drugs, services or supplies.

Prescription drug plan

Your prescription drug benefit is the method of reimbursing members or pharmacies for the cost of drugs, services or supplies.

Prime Specialty Pharmacy

Prime Therapeutics Specialty Pharmacy LLC (called Prime Specialty Pharmacy) fills prescriptions for specialty medicines. Prime Specialty Pharmacy also offers support programs and services to help you get the most benefit from your treatment.

Prior authorization

An extra step that some insurance companies require before they decide if they want to pay for your medicine. The list of drugs needing prior authorization depends on your benefit plan.

Q

Qualified plan

Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by the Health Insurance Marketplace, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements. A qualified health plan will have a certification by each Marketplace in which it is sold.

Quantity dispensed

The number of pills or amount of a medicine that was dispensed for a prescription. This number is shown in units like pills, capsules, ounces, cc’s).

Quantity limits

The maximum amount of a medicine that you can get for each fill. Quantity limits are based on the number of days or number of units (pills, capsules, ounces, etc.).

R

Retail pharmacy

A pharmacy located in a retail store instead of a hospital or clinic.

Retail pharmacy with extended supply

A retail pharmacy where your plan lets you buy up to a 90-day supply of a long-term medicine. Most retail pharmacies can only fill up to a 30-day supply of medicine.

S

Sales tax

Some states charge sales tax for prescriptions. Your plan does not cover any charges for sales tax, and sales tax does not count towards your deductible.

Single source

A medicine that comes from only one source, usually the original manufacturer.

Smart prior authorization

Some prescription medicines - usually newer, brand-name drugs, are subject to smart prior authorization. It means, you may have to try a more common, better-known, drug to treat your condition before you can "step up" to a newer, more expensive drug.

Specialty medicines

Specialty medicines treat chronic and complex conditions (for example, multiple sclerosis, cancer, hepatitis C and rheumatoid arthritis). Specialty medicines can be filled at a specialty pharmacy.

Step therapy

Some prescription medicines, usually newer brand-name drugs, are subject to step therapy. It means you may have to try a more common, better-known drug to treat your condition before you can "step up" to a newer, more expensive drug.

Subscriber

The main person on your benefit plan; usually the person who signed up.

Summary of benefits

The document that describes all of the medical and pharmacy benefits in your plan. It also tells you all of your costs, including your deductible, out-of-pocket maximum, copays, coinsurance.

T

Therapeutic alternative

A medicine that treats a specific health condition as well as a more expensive brand-name drug. It could be a different brand-name drug that has been on the market for a longer time. Or it can be a generic medicine – a lower-cost version of a brand-name drug. Therapeutic alternatives work in a similar way, but have different ingredients.

Therapeutic classification

A system that places prescription medicines into categories, based on their active ingredients.

Therapeutic equivalent

A medicine that treats a specific health condition the same or as well as a differene drug. Both medicines have the same effects and safety standards.

Treatment category

A group of clinical conditions (for example, high blood pressure and high cholesterol) that health care professionals use to figure out how effective different treatments are.

TrOOP

"True out-of-pocket" costs that Medicare members pay for their prescriptions. This can include deductibles, coinsurance and/or copays.

U

Utilization Management

Utilization management

Some medicines on your drug list may have special requirements or rules. In the health care world, this is called utilization management. If you take a medicine with special requirements, work with your doctor to ask your plan for approval.

If you see a note next to a medicine on your drug list, here’s what you should know:

  • PA or prior authorization – a medicine needs to be pre-approved before it can be covered by your plan
  • ST or step therapy – you may need to try a different, less expensive or more common drug first
  • QL or quantity limits – you may only be able to receive a certain amount of your drug at one time