SlideShare a Scribd company logo
pharm get paid! 
•max allowable cost--max price ins co will pay for 
generic 
•capitation fee- pharm gets paid x per pt per 
month, whether or not they come in. 
•deductible--ins co pays nothing until pt pays x 
amount for medical services. 
•copayment--pt pays % of med or x amount and 
ins co pays rest.
3rd party plans 
• HMO health maintenance organization---providers sign 
contract and must follow HMO orders, wont pay outside 
network unless referral. 
• PPO preferred provider organization---providers contract 
with ppo. ins pays less if you go outside PPO. 
• POS point of sale/service---prov under contract. pt must 
choose PCP on the list. PCP must give referral if outside 
network. 
• medicare----federal program for over 65? or disabled or 
kidney failure. 
• medicaid----federal program administered by states who 
determine services and entry. not all drugs paid for. 
• pt assistance program---drug maker offers assistance for 
special needs and affordability. 
• work comp---on the job injury. rx billed to ins co.

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Getpaid

  • 1. pharm get paid! •max allowable cost--max price ins co will pay for generic •capitation fee- pharm gets paid x per pt per month, whether or not they come in. •deductible--ins co pays nothing until pt pays x amount for medical services. •copayment--pt pays % of med or x amount and ins co pays rest.
  • 2. 3rd party plans • HMO health maintenance organization---providers sign contract and must follow HMO orders, wont pay outside network unless referral. • PPO preferred provider organization---providers contract with ppo. ins pays less if you go outside PPO. • POS point of sale/service---prov under contract. pt must choose PCP on the list. PCP must give referral if outside network. • medicare----federal program for over 65? or disabled or kidney failure. • medicaid----federal program administered by states who determine services and entry. not all drugs paid for. • pt assistance program---drug maker offers assistance for special needs and affordability. • work comp---on the job injury. rx billed to ins co.