Managed Care Terminology

Question 1

Deductible

Answer 1

fixed amount that an insured person must pay out-of-pocket before health care benefits become payable

Question 2

Premium

Answer 2

amount paid to a health insurance carrier for providing coverage under a contract

Question 3

Coinsurance

Answer 3

percentage of the costs of health care services/products paid by the patient after deductible

Question 4

Copayment

Answer 4

cost-sharing arrangement in which a covered person pays a specified charge for a specific service

Question 5

Out-of-Pocket Costs

Answer 5

portion of payments for covered health services required to be paid by the enrollee including co-payments, coinsurance, and deductibles

Question 6

Maximum Out-of-Pocket Costs

Answer 6

limit on total member copayments, deductibles, and co-insurance under a health care plan

Question 7

Copay Coupons

Answer 7

discount cards provided by drug manufacturer to patients to reduce patient cost for prescription of non-preferred drugs

Question 8

Health Savings Account

Answer 8

tax-sheltered savings account that may be used by beneficiaries covered by high-deductible health plans to pay for routine health care

Question 9

Format for Formulary Submission (Dossier)

Answer 9

AMCP allowing manufacturers submission of clinical and economic evidence to support formulary considerations

manufactures and MCO use to formalize, standardize, and expand information for P&T Committee review

Question 10

Drug Mix

Answer 10

• evaluation of the type of drugs prescribed by an individual or defined population
• rate of new drug adoption by reviewed physicians