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Prior Authorization

A requirement from an insurance company or health plan that your doctor get approval before you can receive certain medical treatments, tests, or prescriptions.

Utilization Management Techniques

Methods used by health plans to evaluate if a medical service is appropriate, necessary, and efficient, often to control costs or ensure quality.

Medical Necessity Review

A process where a health plan reviews a doctor's recommended treatment to determine if it's considered medically necessary according to the plan's coverage criteria.

Step Therapy (or Fail-First Protocol)

A type of utilization management where a patient must try one or more less expensive or alternative medications (or treatments) before their health plan will cover a more expensive option for the same condition.

Group Health Plan

A health benefit plan offered by an employer or employee organization to its employees and their families.

Health Insurance Issuer

A company or entity that provides health insurance policies or plans.

Federal Health Care Program

Government programs that provide health coverage or services, such as Medicare, Medicaid, TRICARE, and the Federal Employees Health Benefits Program.