MMS Flashcards
1
Q
CCG
A
Client component guide
2
Q
COB
A
Coordination of Benefits
3
Q
CD
A
Coverage determination
4
Q
DAW
A
Dispense as Written
Dr. Request
5
Q
PBM
A
Pharmacy benefit management
6
Q
NPI
A
National provider identifier
7
Q
MOOP
A
Maximum out of pocket
8
Q
TPA
A
Third party administrator
9
Q
PCI
A
Pharmacy incentive program
10
Q
OTC
A
Over the counter
11
Q
OPP
A
Out of pocket
12
Q
Daw2
A
Dispense as written
Member wants this one
13
Q
P&T
A
Pharmacy and Therapeutic
14
Q
PHI
A
Personal health information
15
Q
FAC
A
Formulary advisory committee
16
Q
ST
A
Step therapy
17
Q
GW
A
Generic waver program
18
Q
RxCents
A
Tablet spitting program
19
Q
EOB
A
Explanation of Benefits
20
Q
HIPAA
A
Health insurance portability and Accountability Act
21
Q
BIN
A
Benefit identification number
22
Q
DUR
A
Drug Utilization Report
23
Q
EGWP
A
Employer Group Waiver Plan
24
Q
MAC
A
Manage Care Options
25
NAP
Non-automated PA
26
NPD
Non-Preferred Drug
27
NPI
National provider identifier
28
PCN
Process Control Number
29
PDL
Preferred Drug list
30
PHI
Personal (Protective/Patient) Health information
31
Elig.
Eligibility
32
ETC
Exception to Coverage
33
ST
Step therapy
34
PHI
Personal health information
35
PCG
Program component guides
36
TSF
Telephone service factor
37
ASTS
Average speed to answer
38
CCD
Customer care dashboard
39
PCG's
Program component Guide
40
POA
Power of attorney this must be medical
We must have a copy of medical power of attorney on file
41
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
42
Therapeutic class
Is a drug group used to treat the same illness like cholesterol lowering, antidepressants and Blood pressure
43
Formulary
A preferred drug list that limits the number of drugs available within the therapeutic class for drug purchasing dispensing and or reimbursement
44
Therapeutic class
This is a group of medications the treat the same illness like
cholesterol lowering
antidepressants
blood pressure etc.
45
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
46
Formulary as status
This is the level or tear of the drugs covered on the benefit
47
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
```
48
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
49
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
50
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
51
How long does a drug need to be on the market before a (P&T) committee will consider it.
6 months
52
Rebates are sought for preferred drugs
| What does this determined
This determines which of two equally effective drugs become preferred
53
PCP
Primary care physicians
54
FAC
Formulary advisory committee
55
Who does FAC include
Navitus clinical staff and non-Navitus members
56
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
57
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
58
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
59
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.
60
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
61
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
62
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
63
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
64
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
65
Searching a formulary
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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
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66
There are two general orders of search results for drug names what are they?
1. Alphabetical Index list
| 2. Chapters (therapeutic class)
67
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.
68
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.
69
F
= formulary covered
70
NC
= not covered
71
B
Brand
72
G
Generic
73
TS or cents sign means
Drug is on the RxCents (tablet splitting) program
74
PA
Prior authorization
Drug requires prior authorization before it will be covered.
75
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.
76
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
77
SP
Specialty pharmacy
Drug is available through a specialty pharmacy (voluntary).
78
MSP
Mandatory specialty pharmacy
Members are required to get the drug through a specialty pharmacy.
79
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.
80
RS
Restricted to specialist
81
GW
Generic waiver program the co-pay on the first Month is always free
82
VAC
Drug is part of the vaccination program (listed along with applicable copay).
83
NM
Drug is not available through mail order
84
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.
85
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
86
FBMS
Formulary and benefit management system
87
FBMS
Formulary and Benefits Management System
88
PAR
| What do the letters stand for?
Participating pharmacy
89
PAR
| What is the definition?
Participating pharmacy means
| A pharmacy who has signed a contract agreeing to Navitus reimbursement terms.
90
MO
| What do the letters stand for?
Mail order
91
MO
| What is the definition?
Mail order
| Is the pharmacy but only meals medications.
92
SP
| What does the letter stand for?
Specialty pharmacy
93
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.
94
HCRC
| What do the letters mean?
Health care reform contraceptives
This list can be found under
reference documents forms
95
DMS
| What do the letters stand for?
Disposal medical supplies
96
DMS
| What does this mean
Disposal medical supplies
Means that items used ones and discarded are covered
97
DME
What do the letters stand for?
Durable medical equipment
98
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
99
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.
100
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.
101
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.
102
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
102
HDHP
What do the letters stand for?
High deductible health plans.
103
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.
