These definitions are provided for your general information when using this website. The exact terms and definitions applicable to your benefits are those found in your plan contract, evidence of coverage or member handbook.
The member's ability to obtain medical care. Access can be affected by availability of services, size of the network, location of the facilities, and affordability of coverage. Your health plan offers member access to prescription drugs through our Preferred Mail Service Pharmacy and Network Retail Pharmacies.
Stands for: Angiotensin Converting Enzyme Inhibitors. The class of drugs that are used to treat cardiovascular conditions such as hypertension and heart failure.
An alternative health procedure based on ancient Chinese methods. This traditional form of Chinese medicine uses a technique which involves the passing of needles through the skin to specific points to induce anesthesia, relieve pain, alleviate withdrawal symptoms of substance abuse or treat other various disorders.
A word used for a serious and sudden condition that lasts a short time and is not chronic. Examples include a heart attack, pneumonia or appendicitis.
A claim review step that compares claims to covered services on a plan and determines the amount of payment, if any, for that claim. Also called "adjustment." With our Preferred Mail Service Pharmacy, adjudication is part of the claims processing system and takes place at the time a prescription is dispensed.
A signed legal document that allows you to select a person to make your health care choices at a time when you cannot make them yourself and conveys your decision about your end of life care ahead of time.
Adverse Drug Reaction (ADR)
Occurs when a particular drug is harmful to a patient.
Medical treatment by or under the direction of a physician for allergies, which may include testing, evaluation, injections, or administration of serum.
The maximum amount that a Health Benefit Plan will pay for a given Covered Service or supply. Also called Maximum Benefit Allowance, Maximum Allowance or Reasonable Charge.
Surgical procedures performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called Outpatient Surgery.
Services performed that do not require an overnight hospital stay.
Americans with Disability Act (ADA) is a law that protects people with disabilities from not being treated fairly. The ADA law makes sure there are equal chances for people with disabilities in employment, state and local government services, including health care.
The therapeutic drug class that includes medications used to relieve pain.
Medications that are in the therapeutic drug class used to treat infectious diseases such as community-acquired pneumonia.
Medications that are used to treat cancer
A process used to request that the Health Plan re-consider a previous decision made by the Health Plan or provider. There may be different appeal processes for members, providers, types of products, or state of issue.
Arbitration is the process by which parties to a dispute submit their differences to the judgment of an impartial person or group appointed by mutual consent or statutory provision.
Authorize/Authorization is when a Health Plan approves treatment for covered health care services. Members may have to pay for non-approved treatment. Note: Emergency Services and out-of-area urgent care services usually do not require prior authorization. Your prescription vendor uses pre-approved criteria, developed by our Pharmacy and Therapeutics Committee, and reviewed and adopted by your health plan, to provide authorizations for claims using real-time edits. For certain types of drugs, Prior Authorization is required. Also see Pre-Authorization or pre-approval.