Prepaid health care plans that meet federal legal standards for managed care plans (e.g., health maintenance organizations, provider-sponsored organizations, preferred provider organizations, or other types of network plans except network medical savings account plans). They incorporate cost containment and emphasize preventive care to members of the plans. Also referred to as coordinated care (CC) plans or managed care plans.

Evaluation of insurance claims before determination and payment.

Legal phrase that means the greater the weight of the evidence when weighed with that opposed to it, has the most convincing force to assist with making a judgment. Also called preponderance of proof.

Insurance claim form in which the provider’s name, address, and identification numbers have been reproduced on the form.

Provision in a pension plan that gives a benefit to the surviving spouse of a vested plan participant if the participant deceases before retiring. Qualified plans must include this provision.

Medications that are available only with a written prescription from a licensed practitioner.

Written order for medication, therapy, or therapeutic device given by a physician, dentist, or other licensed practitioner, which then goes to a person authorized to dispense the order.
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Creation (or extinguishment) of a legal right or obligation by the lapse of time.

Management company or organization that monitors prescription claims for managed care plans and tracks the drugs and volume prescribed by the plan’s participating providers of medical services. The PBM’s sophisticated information systems help identify patients who have chronic diseases, drug utilization, compliance patterns, and physicians’ prescribing patterns. Also called pharmacy benefit manager (PBM).

Medication that can be dispensed to the public only with an order given by a properly authorized individual. The drug must be approved by the U.S. Food and Drug Administration (FDA) and only a licensed, registered pharmacist or physician may dispense the prescription.