How the Pharmacy Benefit Manager Does Not Work For You

Common Insurance Terms

Pharmacy Benefit Manager (PBM ): Third party companies such as OptumRX, ExpressScripts, and CVS Scripts that contract with insurance carriers and coordinate with pharmacies to process pharmacy benefit claims. The Big Three process over 70% of pharmacy insurance claims in the United States and they they are not obligated to ensuring patient care or maintaining the standard of care. They promise to reduce costs to insurance carriers and profit from minimizing care to patients. Third Party Administrators (TPA) : Third party companies that are contracted with insurance carriers to administer claims, including adjust and adjudicate, guarantee payment, utilization reviews of medical and pharmacy authorizations, contract with providers, and accept or deny liability. Claims: Payment requests from medical providers or pharmacies submitted to the responsible party. Responsible Party : The responsible party for a claim is the person or entity legally obligated to provide payment...

What is an Explanation of Benefits (EOB)?

If you are dealing with a work-related injury, an ongoing health issue, or simply your family's standard medical needs, you probably receive a lot of paperwork. Some of it isn't easy to understand, and sometimes it's not clear if what you received is a bill for services. Explanation of Benefits (EOB) are statements from the insurance carrier regarding every item billed by a provider. For example, you may go see your primary care physician for an infected finger, but while you're there you may also discuss your current medications, and have your sinuses checked for polyps. Each separate procedure will be submitted to the insurance carrier with a medical billing code, and the insurance carrier decides based on those codes what and how much to pay. Those are the codes that will appear on your Explanation of Benefits. At the bottom of the statement, normally in small print, there will be a legend defining each code. Sometimes those codes are easy to understand--maybe one...

What is an Insurance Election Period?

Because of the nature of insurance plans, you cannot simply enroll or unenroll whenever you wish. Every insurance plan as an annual period called the Open Enrollment Period where you may add, drop, or change the plan without penalty. Generally, if you receive your insurance through your employer, you don't have to do anything to maintain your enrollment--it will continue automatically, but if you would like to change or tier level, switch from HMO to PPO, or unenroll entirely, the Open Enrollment Period is your annual opportunity. Open Enrollment also applies to those who are enrolled in Medicare, Medicaid, or TriCare plans. But you do not always have to wait for Open Enrollment to change your insurance plans. Legally, there are a series of qualifying life events that will provide a time frame--generally 30 to 60 days--in order to make any necessary changes without penalty for adding or dropping a plan. These qualifying life changes include: Marriage or Divorce G...

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