Association group plans
Insurance plans designed for members of a professional association or trade association. Members may be protected under a group policy or by individual franchise policies

Beneficiary
The person who is to receive the drug benefits

Benefit
The drugs for which the insurance plan will reimburse costs

Blue Cross
An independent non-profit membership corporation providing protection against insurable health care costs

Cap
The maximum amount the insurer will pay for medications for a specified certain period. Plans may have a yearly cap or a lifetime cap

Claim
A demand to the insurer by the insured person for the payment of drug costs under a policy

Coinsurance
A provision in a health insurance contract by which the insurer and insured share, in a specific ratio, the covered expenses under a policy. For example, the insurer may reimburse the insured for 80 per cent of covered expenses, the insured paying the remaining 20 per cent of such expenses

Coordination of Benefits
A process through which individuals/families with access to more than one insurance plan and/or drug benefit program sequentially submit their claims to their insurers. The portion of the drug cost not paid for by the first insurer is claimed through the second insurer. See the Coordination of Benefits button on the sidebar

Co-payment / Copay
The portion of the drug cost the insured has to pay. It may be a percentage of the total or a fixed dollar amount per prescription

Covered expenses
Specified hospital, medical and miscellaneous health care expenses that will be considered under a health insurance policy

Deductible
The amount of covered expenses that must be incurred and paid by the insured before drug benefits become payable by the insurer

DIN Drug Identification Number
A unique identification number given to a medication upon its approval by Health Canada for sale in Canada

Extended Health Care Insurance
A form of health insurance that provides, in one policy, protection for hospital and medical expenses not covered by government programs and usually other health care expenses, such as prescribed drugs, medical appliances, ambulance, private duty nursing, etc. The policy may contain a deductible amount, coinsurance and cap maximum benefits. Also called major medical expense insurance

Formulary
A listing of all medications/products that a particular drug plan provides as benefits to its beneficiaries

Formulary Plan / Managed Care Plan
A drug plan that only covers (pays for) medications/products listed on a specific formulary

Group insurance
Insurance issued on a group of people under a master contract. It is usually issued to an employer for the benefit of employees. The individual members of the group hold certificates as evidence of their insurance

Individual insurance
Insurance purchased on an individual basis, covering only one person or, in some cases, members of his or her family as well.

Inpatient
A patient who is hospitalized (staying in the hospital)

Insured
The individual who receives the benefits from the insurer

Insurer
The party to the insurance contract who promises to pay for benefits. Also, any corporation licensed to furnish insurance to the public

Open Access Plan
Plans which cover all prescription drugs unless specifically excluded or restricted (as opposed to managed formulary plans which exclude any drug that is not specifically listed)

Outpatient
A patient who is not hospitalized (not staying in the hospital) but visits the hospital for treatment or to see their physician

Outpatient Medication
A medication that is not taken in the hospital and usually not paid for by the hospital

Premium
The payment, or one of the periodic payments a policyholder is required to make for an insurance policy

Private insurance / Third party insurance
Insurance, including prescription drug benefits, that is usually purchased by an employer, from one of the insurance companies, for their employees. See the Private Insurance button on the sidebar

Reimbursement
Repayment to a beneficiary of the costs or portion of costs incurred to purchase medications listed as a benefit by the insurer

Special authorization
A process where a drug plan or drug benefit program makes a prescriber request coverage for a specific drug (request can be a letter or form detailing the patient's condition, providing specific clinical information and reasons why the medication is necessary) before approval can be granted for reimbursement of the cost of the medication. In some cases there are specific criteria associated with the use of a drug that must be met before approval is granted.