Pharmacy

Facility that medicinal drugs are dispensed and sold.

Specialty Pharmacy

Facility licensed to dispense medications that are high-cost and used in the treatment of complex diseases.

Specialty Pharmacy List

List of pharmacies that are network participants with the chosen health plan.

Specialty Medication List

List of medications that are on the formulary for the treatment of complex diseases. Typically, these are oral, injectable, and infused medications.

HDHP Preventive Drug List

Specific to High Deductible Health Plan. List of medications available under the HSA Preventative Drug Coverage. Actual cost of medication is applied toward the preventative benefit, allowing coverage for medications even when the deductible is not met. Benefits are provided in accordance with the IRS guidance.

Mail Order Pharmacy

Online facility that dispenses non-specialty medicines written by your provider and delivered to your home.

Prior Authorization

Approval from insurance plan for a particular drug in order for the medication to qualify for coverage (completed prior to medication being dispensed).

Essential Drug Lists or Formularies

List of medications selected in regards to disease and public relevance, evidence of efficacy, safety, and comparative cost that satisfy the priority health care needs of a population.

Generic Drug

Medication created to be the same as an already marketed brand-name drug. Differences from name-brand: inactive ingredients such flavoring or preservatives may change, and generally costs less 

Brand-Name Drug

Medication sold under a specific name or trademark that is protected by a patent. Typically is more expensive than the generic version.

Covered After Deductible Prescription Structure

Medications are covered at a percentage after the deductible has been met. Typically, this structure is for High-Deductible Health Plans.

Diabetic Supplies, Space, and Flow Meters

Specific to maintaining, treating, and monitoring Diabetes. Coinsurance is applied.                         

Denial

Refusal by the insurance plan to pay for requested prescription. Common Reasons for Denials: refilling too soon, lack of prior-authorization (provider handles), out-of-network, drug utilization review (flagged as potential problem with prescription based on claims data, provider needs to handle directly).

Appeals

Member has the right to request a review of a denial/decision made by the insurance plan.