P
Partial Day Treatment
A program offered by psychiatric facilities that includes either a day or evening treatment program for mental health or substance abuse. An alternative to inpatient treatment.
Participating Provider
A doctor or hospital who has agreed to participate in your health plan network and accept your insurance. Each plan has its own network. And getting care from participating providers is often a good way to get quality care at a more reasonable cost.
PCP
Short for Primary Care Physician. Your main doctor or family doctor. You see them for checkups and preventive care. They look out for your whole health, and they’re also your first stop if you are sick or injured (unless it’s an emergency). With some health plans, especially HMO plans, you may need to go through your PCP to get a referral to other doctors — like specialists.
Pharmacy
A place to get prescribed drugs.
Pharmacy Benefit Manager (PBM)
A company that administers and manages your prescription drug benefits.
Physical Therapy
Treatment involving physical movement to relieve pain, restore function and prevent disability after a disease, injury, or loss of limb.
Physician
Another word for a medical doctor.
Point of Service (POS)
A type of health benefit plan that usually offers three different ways, or three “tiers,” to get care:
- You pay the least for care if you choose a main doctor, also called a primary care doctor, in the network to manage your care. You go through your main doctor to see specialists.
- You pay a bit more to see specialists or doctors in your network without a referral.
- You pay even more to see a doctor who isn’t in the network.
Pre-Authorization/Pre-Certification/Pre-Approval
Pre-Authorization, pre-certification, and pre-approval all mean the same thing. It’s a process to determine if the proposed healthcare or service is medically necessary.
It helps determine if certain outpatient care, elective inpatient hospital stay, non-Emergency care, technology or procedure is medically necessary. It requires a healthcare doctor or facility to get pre-approval before providing specific services or procedures. Prior authorization is required for many services. Emergency or out-of-area urgent care services do not need prior authorization.
If you have questions or to check if your treatment needs pre-authorization, call the Member Services number listed on the back of your ID card.
Pre-existing Condition
A health condition that was diagnosed or treated before you enrolled in a health benefit plan.
Preferred Provider Organization (PPO)
A type of health coverage plan that covers services from almost any doctor or hospital. But you’ll almost always pay less for the same level of care when you go to one in your health plan network. You don’t usually need a referral from your main doctor, also called a primary care physician or primary care doctor, to see a specialist.
Premium
The amount you pay to us for your coverage, usually monthly. If you have health coverage through your work, your employer may share the cost of your premium.
Prescription
A doctor’s order for a drug or other item or service to help in your care.
Prescription Drug
A drug that can only be used if ordered by a doctor.
Prescription Drug Tiers
Prescription drugs are put into different categories based on how much they cost, whether they’re brand-name or generic and sometimes other factors. Tier 1 drugs have the lowest copayment and are mostly generic versions of brand-name drugs. Tier 2 is made up of mid-priced drugs that may be brand-name but are “preferred” within their drug class. Tier 3 has mostly brand-name drugs with higher copayments.
Preventive Care
Tests or treatments that may help you stay healthy or catch problems early on when they’re easier to treat.
Primary Care
A basic level of healthcare usually rendered in ambulatory settings by general doctors, family doctors, internist, obstetricians, pediatricians, and mid-level doctors. This type of care emphasizes caring for the member’s general health needs as opposed to specialists focusing on specific needs.
Primary Care Physician (PCP)
Your main doctor or family doctor. You see them for checkups and preventive care. They look out for your whole health, and they’re also your first stop if you are sick or injured (unless it’s an emergency). With some health plans, especially HMO plans, you may need to go through your PCP to get a referral to other doctors — like specialists.
Prior Authorization
For some healthcare services, you or your doctor needs to let us know about it ahead of time. We ask this so we can check whether it’s covered by your plan. During this step, we may also double check that it makes sense and does not conflict with other care you’re getting, or medications you’re taking. Also sometimes called pre-certification, authorization, certification or pre-authorization.
Prosthesis/Prosthetic Device
A device which replaces all or portion of a part of the human body.
Provider
A doctor, hospital or other person or company that provides healthcare services.
Provider Directory
A list of doctors, hospitals, and other healthcare providers.
Provider Network
Doctors and hospitals who’ve agreed to accept your insurance. Each plan has its own network. And getting care from your network is often a good way to get quality care at a more reasonable cost. See also Network and Network Provider.
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