CCG/Benefit Terms Flashcards
Smoking Cessation
Per the Affordable Care Act (ACA) plans must allow members 180 days (6 months) of access to Smoking Cessation products at $0 copay per Calendar Year. This means that if a member were to start the quitting process 7/1, they could get 6 months of products at $0 copay, and have another 6 months of $0 copay products from 1/1-6/30 of the following year.
MOOP
Maximum Out Of Pocket. Member copays accumulate toward a Maximum Out of Pocket amount, if the plan has one. Once reached, the member will have $0 copays for certain medication tiers on the plan.
Deductible
If a plan has a deductible the member pays the full contracted rate for all medications until the deductible dollar amount is met.
TPA
Third Party Administrator. Manages the administration of the benefit for an employer or health plan. They do not pay claims (Navitus is not a TPA but we work closely with them; TPA title is only for dental, vision or health coverage – Navitus manages Pharmacy benefits.)
Cost Sharing
Difference in cost (contracted rate) between the brand and generic, PLUS the copay. See ‘Generic Limit (Cost Sharing)’ FAQ. Not all clients participate, see Generic Limit section of CCG for particular clients benefits. Charge could depend on DAW.
P and T Committee
The Pharmacy and Therapeutics Committee is comprised of physicians and pharmacists actively practicing in the state of Wisconsin that meet quarterly.
Bioequivalent
The generic drug must have the exact same active ingredients delivered to the body at the same time, and used by the body in the same way as the brand drug. Differences between a Brand and generic medication are limited to inactive ingredients, including dyes, buffers and fillers. Bioequivalent drugs should produce the same clinical results as the brand name.
Brand medications
Listed in CAPITAL letters on formularies
Available from one manufacturer (I.e. Nike,GAP, etc.). Protected from competition by a patent so the manufacturer can name the price. Patent life is typically 7 to 10 years.
Generic medications
Typically available from multiple manufacturers in a short time
Generics are typically less expensive than brand drugs because generic manufacturers don’t need to recoup high research and development costs.
Generics are normally sold under their chemical name.
Subscriber
A primary cardholder who is enrolled for single or family coverage and whose dependents may also be eligible for benefits. Can be identified in NCRx as being person code “01”.
Copayment
A specified flat-rate dollar amount that the member must pay each time covered prescriptions are provided, subject to any maximums specified by the benefit.
Coinsurance
A percentage of the cost for covered products an insured is required to pay.
Benefit/plan year
12-month period* in which benefit utilization is accumulated. At the beginning of the plan year, most accruals “zero out” such as a MOOP. (*Most are 1/1-12/31 but not all; Some Dean Health Plans start 7/1, for example).
Retail
Storefront a member can walk into and have a prescription filled. (I.e. Walgreens, Wal-Mart, CVS, Target, RightAid, etc.)
Mail Order (MO)
Mail Order – a pharmacy that only mails medications. Mail order 90DS fills typically offer a savings, as mail order pharmacies buy in bulk and don’t have retail overhead. No storefront option.
