A new treatment developed from research that is different from the commonly provided standard of care for a given disease, illness or condition. Experimental or investigational drugs, treatments or procedures are typically not approved for use by the FDA, and may be the subject of clinical trials to test toxicity, efficacy or effectiveness . Payments to providers based on the specific services rendered. A formulary may limit the type and number of medications available for a physician to select from when treating any given disease, illness or condition. Health benefits purchased to cover individuals who are grouped together for purposes other than purchasing health insurance coverage.
Employers often sponsor group insurance plans for their employees.
Group plans tend to be less expensive than individual non-group plans because the health plan can spread the administrative costs and health risks over more individuals. Unions and churches may also sponsor group insurance plans. A decision by an insurer or its designated utilization review organization to deny, reduce or terminate a requested service, treatment or procedure. The denial must be based on a review and a decision that the requested service, treatment or procedure does not meet the insurer's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness . Non-Group Insurance Plan.