|
Retiree Medical, Prescription Drug and Mental Health and Substance Abuse Programs - RR Donnelley   
How the Prescription Drug Program Works
Glossary of Key Terms
Certain terms have special meaning under the Prescription Drug Program. The claims administrator may have additional definitions that may apply to the services you receive and will always have the discretionary authority to interpret the meaning of these terms and the benefits payable under the Prescription Drug Program.
Charges – the actual billed charges, except when the provider has contracted directly or indirectly for a different amount.
Contract Amount – a predetermined amount to be covered or allowed for a service or procedure as outlined in the provider contract.
Copayment – the minimum fixed-dollar amount that you or your spouse is required to pay for a prescription (if any) in addition to your coinsurance.
Covered Expenses – the expenses that the Prescription Drug Program will cover. To be considered a covered expense, an expense must qualify in each of the following ways:
 | Must be determined by the appropriate claims administrator to meet the definition of “medically necessary” for the specific illness or injury;
|
| Cannot exceed the usual and customary limit for the service as determined by the appropriate claims administrator; and
|
| Is not excluded from being a Covered Expense. |
In-Network Benefit Level – the benefit level payable when services are provided by participating providers and authorized by the claims administrator.
Maintenance Medications – a list, as the claims administrator designates, of prescription drug products that are commonly prescribed for long-term use. This list is subject to periodic review and modification by the claims administrator. Contact the claims administrator to obtain a copy of the list of maintenance medications.
Medically Necessary – the determination of whether a particular service or supply is medically necessary is based on whether the:
| Service or supply is for the treatment, diagnosis, or symptoms of an injury, disease, or condition (including pregnancy);
|
| Service or supply is consistent with the diagnosis and is appropriate given the symptoms;
|
| Type, level, and length of care; the treatment or medical supply; and the setting are needed to provide safe and adequate care; and
|
| Care is not research-related or not generally regarded as experimental or investigational in nature. |
The claims administrator makes the final determination of whether a service or supply is medically necessary.
National Drug Code Number (NDC#) – the national classification system used to identify drugs. This code is an 11-digit number. This number is required on the claim form you complete to receive reimbursement for costs you incur through the use of a retail non-participating pharmacy.
Non-Participating Provider – a provider who does not have a contractual relationship with the claims administrator.
Out-of-Network Benefit Level – the benefit level payable when services are provided by non-participating providers or when not authorized by the claims administrator.
Participating Pharmacy – a pharmacy that is part of the claims administrator’s network and contracts to provide services for the Prescription Drug Program. Contact the claims administrator for a free listing of participating pharmacies, or view the current listing on the claims administrator’s website.
Participating Provider – a provider who has a contractual relationship with the claims administrator.
Prescription Order – a physician’s lawful authorization for a prescription drug or related supply. The physician must be duly licensed to make such authorization within the course of his or her professional practice for each authorized refill thereof.
Primary/Preferred Drug List – a clinically based drug list that contains Food and Drug Administration-approved brand-name and generic medications for a broad range of medical conditions or diseases. While physicians are encouraged to prescribe medications that are on the Primary/Preferred Drug List, it is still the physician’s responsibility to determine the most appropriate medication for each patient. Using a primary/preferred drug, where available and medically appropriate, can reduce your out-of-pocket expenses.
|
