PBM Glossary Terms M-N
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!
Managed Care
Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires pre-authorization of certain services.
Member
A subscriber or dependent who is enrolled in and covered by a health care plan.
Member Services
The PreferredChoices® Member Services department assists members with questions about plan benefits and exclusions and, if applicable to your plan, selecting or changing a primary care physician (PCP). Calling the toll-free number on your ID card will connect you with your plan's PreferredChoices® Member Services office. If you do not have your ID card yet, contact your employer's benefits office for your Member Services toll-free number.
Mental Disorder
A dysfunctional manifestation in the individual that may be physical, psychological or behavioral, and for which treatment is generally provided by under the direction of a mental health professional such as a psychiatrist, a psychologist or a psychiatric social worker
National Committee for Quality Assurance (NCQA)
The National Committee for Quality Assurance (NCQA) is an independent, not-for-profit organization that evaluates managed care plans. The NCQA accreditation process is nationally recognized and evaluates how well a health plan manages all aspects of its medical delivery system and the extent to which it continuously improves health care for its members.
Necessary, Medically Necessary, Medically Necessary Services, or Medical Necessity
Services or supplies that are appropriate and consistent with the diagnosis in accordance with accepted medical standards as described in the Covered Benefits section of the plan documents. Medical Necessity, when used in relation to services, shall Page 5 of 7 have the same meaning as Medically Necessary Services. This definition applies only to the determination by the Plan of whether health care services are covered benefits under the plan. All services are subject to the exclusions and limitations
described in the plan documents.
Non-Participating Provider
This term is generally used to mean providers who have not contracted with a health plan to provide services at reduced fees. Also called Non-Preferred Care Provider.
