Below is a list of common terms and their definitions:
Appeal – A request for an insurance company to review and reconsider its decision to deny payment for a patient’s medication or procedure.
Appointment of Representative Form – This form allows a patient to appoint someone to act on his/her behalf during an appeals process with an insurer.
Claim – A detailed invoice that a healthcare provider sends to a patient’s insurance plan to receive payment for services provided.
Co-insurance – This is the amount a patient pays for his/her healthcare after meeting the deductible. The amount is based on a percentage of the cost of services and/or medications.
Commercial insurance – This type of insurance is given by a patient’s employer or purchased individually through a healthcare exchange. It could also be part of a patient’s retirement package from an employer.
Co-pay – The flat dollar amount a patient pays out of pocket when visiting a doctor’s office, going to the emergency room, or filling a prescription at the pharmacy.
Deductible – The amount that a patient pays each year before insurance will begin to pay for the patient’s healthcare. Once a patient meets the deductible, the insurance begins to pay its share of the patient’s healthcare costs.
Denial – This is when an insurance plan refuses to pay for a medicine or service prescribed or recommended by a healthcare professional. This decision may be appealed.
Dual eligibility – A patient is qualified to receive both Medicare Part A and/or Part B services and also some form of Medicaid benefit.
Insurance premium – The amount the policy holder or his/her sponsor (eg, an employer) pays to the insurance plan to purchase health coverage. Premiums are usually paid on a monthly basis.
Low-income subsidy – This applies to Medicare Part D only. This is government aid given to low-income patients to help pay for the costs associated with Medicare Part D. Patients must apply to receive this aid.
Medicaid – This is a government insurance program that helps patients with low income pay for medical care; this program differs by state.
Medicare – This is a government insurance program for people who are 65 or older, certain younger people with disabilities, and people with end-stage renal disease.
Medigap – Various private health insurance plans sold to supplement Medicare insurance.
Open enrollment – The time of year when people can enroll in a health plan. This time period varies by plan but generally falls between November 1 and December 15.
Out-of-pocket costs – The amount a patient pays out of his/her own pocket for healthcare. Costs include deductibles, co-payments, co-insurance, and any medical expenses that are not covered by insurance.
Out-of-pocket maximum – The most a patient has to pay for covered services in a plan year. After a patient spends this amount on deductibles, co-payments, and co-insurance, the health plan pays 100% of the costs of covered benefits.
Prior authorization/precertification – Some treatments and/or procedures require a prior insurance approval to determine whether the insurance company will pay for the prescribed medicine or procedure.
Reimbursement – The way an insurance plan pays a patient or healthcare professional for a product or service.
Risk Evaluation and Mitigation Strategies (REMS) – These programs are mandated by the Food and Drug Administration (FDA) because of the risks associated with certain medications. It may be mandated by FDA that the medication is dispensed only by certified pharmacies.
Special enrollment period – A time outside the yearly open enrollment period when a patient can sign up for health insurance. A patient may qualify for a special enrollment period if you’ve had certain life events, including losing health coverage, moving, getting married, having a baby, or adopting a child.
TRICARE – A military health insurance program for active-duty members, retirees, and their families.
Underinsured – When a patient has some healthcare coverage, but not enough to cover the full cost of treatment.
Uninsured – When a patient has no healthcare coverage.
Veterans coverage – Government-sponsored healthcare benefits available to veterans, dependents, survivors, and uniformed service members. It is run by the Department of Veterans Affairs.
REVLIMID® (lenalidomide), POMALYST® (pomalidomide), and THALOMID® (thalidomide) are only available through restricted distribution programs.
Please see full Prescribing Information, including Boxed WARNINGS, for REVLIMID®, POMALYST®, THALOMID®, IDHIFA® (enasidenib), and ABRAXANE® for Injectable Suspension (paclitaxel protein-bound particles for injectable suspension) (albumin-bound). Please see full Prescribing Information for VIDAZA® (azacitidine for injection).
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The ICD-10-CM Codes provided here are for diagnoses reasonably related to an indication or indications within the product’s approved label and are provided for your reference only. Other codes may be appropriate. Celgene makes no representation that any code is appropriate for a particular patient. Healthcare Professionals must use their independent judgment in selecting Code(s) to accurately reflect the diagnosis of the specific patient.