ACCESS & REIMBURSEMENT GLOSSARY
Search a small public set of reviewed terms. Every entry separates an official-source summary from PharmaARMs context. The expanded glossary and saved terms remain reserved for authorized members.
REVIEWED FOUNDATION
These entries support general professional education. They do not determine coverage, authorization requirements, cost, coding, billing, eligibility, or what applies to a particular person or case.
Search the currently published terms below. Saved terms and the expanded member glossary remain planned.
Also: preauthorization, prior approval, precertification
A health plan approval that may be required before a service is received or a prescription is filled for plan coverage.
Requirements differ by plan, benefit, service, drug, setting, and circumstance. The term alone does not establish whether authorization is required or whether a claim will be paid.
Also: drug list
A list of prescription drugs covered by a prescription drug plan or another insurance plan with prescription benefits.
A drug list can change and may include tiers or utilization requirements. Verify the current plan document and effective date.
Also: annual deductible
An amount a person pays for covered health care services before the insurance plan begins paying under its terms.
Plan design varies. Some services or benefits may follow different deductibles or rules, so the controlling plan documents matter.
Also: co-insurance
A percentage of the cost of a covered health care service that a person pays, often after meeting the applicable deductible.
The relevant percentage and allowed amount depend on the plan and service. This definition does not calculate an individual cost.
Also: out-of-pocket share
The portion of covered costs paid out of pocket, generally including deductibles, coinsurance, copayments, or similar charges.
The term can be used differently across programs; confirm which amounts are included in the applicable plan or program source.
Also: NCD
A CMS determination addressing whether a particular item or service is covered nationally under Medicare.
A title or acronym is not enough to determine current coverage. Review the applicable document, version, effective date, benefit category, and implementation material.
Also: LCD
A Medicare Administrative Contractor determination addressing coverage of an item or service within the contractor jurisdiction.
Jurisdiction, document status, version, effective date, associated articles, and any controlling national policy must be checked.
Also: Federal Employees Health Benefits
The Federal Employees Health Benefits law or program.
Benefits and limitations are described in the applicable current plan brochure. The acronym alone does not establish a person’s benefits or eligibility.
Do not infer an answer from a related definition. Use the applicable current plan, payer, program, contract, policy, or official source and the appropriate qualified professional.
