MMS Flashcards
CCG
Client component guide
COB
Coordination of Benefits
CD
Coverage determination
DAW
Dispense as Written
Dr. Request
PBM
Pharmacy benefit management
NPI
National provider identifier
MOOP
Maximum out of pocket
TPA
Third party administrator
PCI
Pharmacy incentive program
OTC
Over the counter
OPP
Out of pocket
Daw2
Dispense as written
Member wants this one
P&T
Pharmacy and Therapeutic
PHI
Personal health information
FAC
Formulary advisory committee
ST
Step therapy
GW
Generic waver program
RxCents
Tablet spitting program
EOB
Explanation of Benefits
HIPAA
Health insurance portability and Accountability Act
BIN
Benefit identification number
DUR
Drug Utilization Report
EGWP
Employer Group Waiver Plan
MAC
Manage Care Options
NAP
Non-automated PA
NPD
Non-Preferred Drug
NPI
National provider identifier
PCN
Process Control Number
PDL
Preferred Drug list
PHI
Personal (Protective/Patient) Health information
Elig.
Eligibility
ETC
Exception to Coverage
ST
Step therapy
PHI
Personal health information
PCG
Program component guides
TSF
Telephone service factor
ASTS
Average speed to answer
CCD
Customer care dashboard
PCG’s
Program component Guide
POA
Power of attorney this must be medical
We must have a copy of medical power of attorney on file
Formulary
Is the preferred drug list that limits the number of drugs available with in a therapeutic class for drug purchasing, dispensing and or reimbursement
Therapeutic class
Is a drug group used to treat the same illness like cholesterol lowering, antidepressants and Blood pressure
Formulary
A preferred drug list that limits the number of drugs available within the therapeutic class for drug purchasing dispensing and or reimbursement
Therapeutic class
This is a group of medications the treat the same illness like
cholesterol lowering
antidepressants
blood pressure etc.
Formulary as a thing
The physical documentation list of the drugs names and associated information the formulary access to put coverage included drugs that are covered not covered and covered at a less than optimal right
Formulary as status
This is the level or tear of the drugs covered on the benefit
Drugs are either formulary or non-formulary
Formulary means the medication is therapeutically preferred and is therefore covered better for the patient Non-formulary means the medication is covered but is not preferred in its class and is therefore not covered as well for the patient
P&T committee
Pharmacy and therapeutics committee
Navitus formulary is a drug list established to be clinically sound and cost-effective by the pharmacy and therapeutics committee
The (P&T Committee) pharmacy & therapeutic committee
Drug products are evaluated on four criteria in order
what are they?
Effectiveness
Side - effects
Drug interactions
Value the cost
FDA
Food and drug administration department of Health and Human Services which reviews and monitors, regulates diet supplementary, medical and cosmetic products as well as electronic products that emits radiation
How long does a drug need to be on the market before a (P&T) committee will consider it.
6 months
Rebates are sought for preferred drugs
What does this determined
This determines which of two equally effective drugs become preferred
PCP
Primary care physicians
FAC
Formulary advisory committee
Who does FAC include
Navitus clinical staff and non-Navitus members
What does the FAC group do
They meet monthly
They meet monthly to address clinical issues facing Navitus or the pharmacy industry
Some topics can include
the release of the new generics for currently rebated brand products
drug recalls and shortages
High-Appeal medications
Tell me about brand name
Brand products are listed in all capital letters
They are only available from one manufacture because they are Protected from competition by a patent
The patent can last 7 to 10
So the manufactures can name there price
Tell me about Generic drugs
They are listed in all lowercase letters
When a patent on the brand product has expired
Typically they are available from multiple manufacturers in a short time
When generic comes out typically brand and generic are covered at the same tear
The competition increases and the generic price goes down
Just because the drug is generic it does not mean it will be covered at the lowest patients pay them out
Some clients use a tier and some use space level placement
What do they mean?
Tearing or level is the placement of a drug on the formulary based on what the cost sharing is between the member and the client.
Tiering or level can vary for each client.
It maybe the same but have different cost sharing associated with them.
tier 2 maybe a $20 co-pay on one plan and have a 25% coinsurance on another.
What is traditional formulary?
Tier - 1 all covered generics
Tier - 2 preferred brand products
Tier - 3 non-preferred brand products
New products are not covered until they are reviewed by the P&T committee
What is the select formulary?
Tier - 1 formulary generics and some lower cost brand products
Tier - 2 formulary brand products and some high cost generics
Tier - 3 non-preferred formulary products this could include some high cost generics
This is the closed highly managed formulary
New products will not be considered until their reviewed by the P&T committee
What is Open formulary?
Tier 1. MONY Y (generics)
Tier 2. MONY M, N, O (Brand)
New products to the market will be placed on the formula based on their multi- source Moni code
What is managed formulary?
Tier 1. All formulary generics and some lower-cost brand Products
Tier 2. Formulary brand products
Tier 3. Non-preferred formulary products
Any new products to the market will be placed on tier 3
QRF
What does QRS mean?
(QRF) Quick reference formulary
This is a 1 to 2 page document of the most common drug classes and most commonly used medications in those classes
Searching a formulary
Customer care dashboard CCG Formulary, PA Tab Click correct clients formulary Open the Adobe binocular's Type in the drug name it can be a partial Then enter
There are two general orders of search results for drug names what are they?
- Alphabetical Index list
2. Chapters (therapeutic class)
There are two general order of search results for medications one is alphabetical Index list what information does this give you.
Medications are listed in alphabetical order.
This list the drug, any special codes, the coverage level, and the name of the chapter it is in.
There are two general orders for medications one is sorted by chapters (therapeutic class). What information does this give you?
Medications are listed by drug class.
Each chapter, groups drugs by category like antidepressants and anti-psychotic and shows which tier/level a drug is on.
The chapter Lists drug name, special codes the most commonly prescribed strength and quantity of that strength and coverage level.
F
= formulary covered
NC
= not covered
B
Brand
G
Generic
TS or cents sign means
Drug is on the RxCents (tablet splitting) program
PA
Prior authorization
Drug requires prior authorization before it will be covered.
NP
Non-preferred
Non preferred by the plan, but still available for members. The client may not receive rebates on some medications and may, therefore designate them non-preferred. For this reason they are often available at higher co-pays.
PA* or (Tier)*
Prior authorization* or (Tier)
Drug is covered without a PA, but if the patient meets certain PA criteria, they receive the drug for lower patient Pay amount.
Example drug is covered at a tier 3 without a PA but with an approved PA it is covered at tier 2
SP
Specialty pharmacy
Drug is available through a specialty pharmacy (voluntary).
MSP
Mandatory specialty pharmacy
Members are required to get the drug through a specialty pharmacy.
QL
Quantity limit
There is a quantity limit to how much of a drug the patient may receive each fill and/or Limit of fills per month.
RS
Restricted to specialist
GW
Generic waiver program the co-pay on the first Month is always free
VAC
Drug is part of the vaccination program (listed along with applicable copay).
NM
Drug is not available through mail order
A rate
What does this mean?
This means that the generic is interchangeable with the brand-name. Pharmacist can interchange this without approval from the doctor.
B rate
What does this mean?
This means that The generic is not considered interchangeable so pharmacies can only substitute this generic for Brand product with physician approval
FBMS
Formulary and benefit management system
FBMS
Formulary and Benefits Management System
PAR
What do the letters stand for?
Participating pharmacy
PAR
What is the definition?
Participating pharmacy means
A pharmacy who has signed a contract agreeing to Navitus reimbursement terms.
MO
What do the letters stand for?
Mail order
MO
What is the definition?
Mail order
Is the pharmacy but only meals medications.
SP
What does the letter stand for?
Specialty pharmacy
SP
What is the definition?
Specialty pharmacy
They specialize in medications for chronic disease management, medications only approved to be dispensed by select pharmacies, and most injectable medications. This pharmacy also mails all medication.
HCRC
What do the letters mean?
Health care reform contraceptives
This list can be found under
reference documents forms
DMS
What do the letters stand for?
Disposal medical supplies
DMS
What does this mean
Disposal medical supplies
Means that items used ones and discarded are covered
DME
What do the letters stand for?
Durable medical equipment
DME
What is the definition?
Durable medical equipment
Reusable devices or appliances. Navitus covers few DMEs such as diabetic meters. The majority of the DMEs are a medical benefit such as diabetic pump supplies, support stockings, and canes, even though a member may have a script and be able to get them at a pharmacy
Refill rules
How soon a member can refill their medications, based on the day supply they receive and a percentage of medication used. If no refill schedule section is listed, it follows the standard 70% for 30 DS, and 50% for a 90 DS.
Forgotten meds
Whether a plan will allow an early fill of a members medication (sooner than the refill schedule percentages listed above’ due to have forgotten their meds in another location that they will have access to at a later date.
Replacement meds
Whether the plan will allow an early fill of a members medication (sooner than the refill schedule) for meds that they cannot recoup (lost, stolen, damaged etc.
Vacation
Whether the plan will allow an early fill of a members medication for supplies needed due to not having access to a pharmacy or inconvenience while traveling
HDHP
What do the letters stand for?
High deductible health plans.
Discount RX card
LowestMed discount program is offered to individuals by enrolling online or through a broker it may be referred to as a discount RX card this offering is a smart phone app that anyone can access.
