PBM Glossary Terms E

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PBM QUESTIONS SELF-INSURING QUESTIONS GLOSSARY TERMS A-B GLOSSARY TERMS C GLOSSARY TERMS D GLOSSARY TERMS E GLOSSARY TERMS F-G GLOSSARY TERMS H GLOSSARY TERMS I-L GLOSSARY TERMS M-N GLOSSARY TERMS O GLOSSARY TERMS P GLOSSARY TERMS R GLOSSARY TERMS S GLOSSARY TERMS U-W

Appro-Rx helps improve the way pharmacy benefits management is done every day to help lower prescription costs. However, we understand that the world of PBMs can be confusing. Below we have answered your most frequently asked questions to give you a better understanding of your needs!

Effective Date

The date on which the coverage under a member's plan goes into effect at 12:01a.m

Embedded Deductible

The amount You and Your Dependents must pay for Covered Services including Prescription Drugs within a calendar year, be foreany benefits will be paid by the Plan. The single Deductible is the amount each Covered Person must pay. The family Deductible is the total amount any two or more covered family members must pay.

Emergency

An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman and her unborn child) in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part. Also called Medical Emergency.An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman and her unborn child) in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part. Also called Medical Emergency.

Enrollee

A subscriber or dependent who is enrolled in and covered by a health care plan.

Exclusions

Specific conditions or circumstances that are not covered for benefits under the Plan.

Explanation of Benefits

For certain PreferredChoices® plans, an Explanation of Benefits form is provided to members to explain how the payment amount for a health benefit claim was calculated. Among other things, the Explanation of Benefits may explain the claims appeal process.