Glossary of Terms
Access to Care — The ability of individuals to obtain health services when needed.
Accumulator Program — A tactic by insurance companies that prevents any of the amounts that the patient has paid using manufacturer assistance from counting toward the patient’s out-of-pocket costs.
Affordable Care Act (ACA) — U.S. healthcare reform law that expanded access to health insurance, increased consumer protections, and emphasized prevention and wellness.
Alternative Funding Programs (AFPs) — Third parties that shift or deflect coverage for specialty drugs and treatments on behalf of a health plan sponsor, like an employer.
Biologics — A class of drugs that are produced using a living system, such as a microorganism, plant cell, or animal cell.
Biomarkers — Biological molecules that indicate a process or condition in the body, often used for diagnosis.
Biosimilar — A biological medicinal product that is nearly identical to the original product, but created by a separate manufacturer.
Brown Bagging — A practice where patients pick up their medications from a pharmacy and then bring them to their healthcare provider for administration.
Centers for Disease Control and Prevention (CDC) — The national public health institute in the United States that conducts and supports health promotion, prevention, and preparedness activities.
Centers for Medicare & Medicaid Services (CMS) — A federal agency that administers the nation’s major healthcare programs including Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).
Chronic Disease Management — An approach to healthcare that involves ongoing care and support to individuals with chronic health conditions, including autoimmune diseases.
Clinical Guidelines — Systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.
Clinical Trial — Research studies performed in people that are aimed at evaluating a medical, surgical, or behavioral intervention.
Disease Burden — The impact of a health problem on an individual or population, measured by financial cost, mortality, morbidity, or other indicators.
Drug Formulary — A list of prescription medications covered by a prescription drug plan or another insurance plan offering prescription drug benefits.
Formulary Tiering — Used by Pharmacy Benefit Managers (PBMs)/health insurance plans to categorize prescription medications into different tiers generally based on their cost and clinical effectiveness. Typically, medications in lower tiers have lower copayments or coinsurance for patients, while those in higher tiers require higher out-of-pocket costs. Tiering may also be based on factors some with perverse incentives.
Health Disparities — Preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.
Health Equity — The state in which everyone has a fair and just opportunity to attain their highest level of health.
Health Policy — Decisions, plans, and actions undertaken to achieve specific health care goals within a society.
Health Insurance Portability and Accountability Act (HIPAA) — U.S. legislation that provides data privacy and security provisions for safeguarding medical information.
Informed Consent — The process by which a patient learns about and understands the purpose, benefits, and potential risks of a medical or surgical intervention, including clinical trials, and then agrees to receive the treatment or participate in the trial.
Maximizer Program — A tactic by insurance companies that exhausts the maximum available patient assistance that a drug manufacturer offers to patients for prescription medicines, and does so in a manner that does not count that assistance toward patients’ annual cost-sharing limits.
Medicaid — A state-run, partially federally funded program that helps with medical costs for some people with limited income and resources.
Medicare — A federal health insurance program for people who are 65 or older and certain younger people with disabilities.
Medicare Part D — A federal government program that help seniors and people with long-term disabilities who are Medicare beneficiaries pay for self-administered prescription drugs.
Non-Medical Switching — When an insurance company changes its terms or coverage of a medication for reasons that are not clinically based or medically recommended. This requires the patient to stop taking a medicine and switch to a different treatment that has not been recommended by a medical doctor or other qualified provider, but is preferred by the insurance company for financial reasons.
Office of Autoimmune Disease Research (OADR) — A governmental or organizational entity dedicated to researching autoimmune diseases. Its primary focus is on understanding the causes, mechanisms, treatments, and potential cures for autoimmune conditions.
Orphan Drug — A pharmaceutical agent developed to treat medical conditions which, because they are so rare, would not be profitable to produce without government assistance.
Patient Advocacy — Activities aimed at representing the interests and rights of patients within the health care system.
Patient-Centered Care — Providing care that is respectful of, and responsive to, individual patient preferences, needs, and values.
Pharmacy Benefit Managers — Corporations that administer drug prescription plans for insurance companies; they manage high-cost specialty medication. They help to control what medications are available, which can potentially restrict access for patients.
Prior Authorization — A process used by healthcare insurers or managed care organizations to determine if they will cover the cost of a prescribed medication or medical service. Healthcare providers must obtain approval from the insurer before the medication or service can be provided. This process typically involves submitting documentation to demonstrate the medical necessity of the treatment.
Public Health — The science and art of preventing disease, prolonging life, and promoting health through organized community efforts.
Quality of Care — The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
Reimbursement — Compensation or repayment for healthcare services, often by insurance providers.
Research and Development (R&D) — Activities undertaken by companies and organizations to innovate and introduce new products and services, including medical research.
Specialty Pharmacy — Pharmacies that focus on high-cost, high-complexity, and/or high-touch medication therapy for patients with complex diseases.
Stakeholders — Individuals or groups with an interest in healthcare policy, including patients, providers, payers, and policymakers.
Step Therapy — Insurance company tactic that often requires patients to “fail first” on one or more drugs before getting the medicine that doctors originally prescribed.
Utilization Management Protocols — The use of managed care techniques such as prior authorization and step therapy that allow insurance companies to manage the cost of healthcare by assessing whether patients can receive necessary medication that their physicians have prescribed.
Value-Based Care — A healthcare delivery model in which providers are paid based on patient health outcomes.
White Bagging — The practice in healthcare where a patient’s medication is dispensed by a specialty pharmacy and then shipped directly to the healthcare provider (e.g., a clinic, hospital) for administration.
340B Program — A federal initiative in the United States that allows certain eligible healthcare organizations, known as covered entities, to purchase outpatient prescription drugs at discounted prices.