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Member Services Abbreviations > MMS > Flashcards

MMS Flashcards

1
Q

CCG

A

Client component guide

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2
Q

COB

A

Coordination of Benefits

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3
Q

CD

A

Coverage determination

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4
Q

DAW

A

Dispense as Written

Dr. Request

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5
Q

PBM

A

Pharmacy benefit management

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6
Q

NPI

A

National provider identifier

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7
Q

MOOP

A

Maximum out of pocket

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8
Q

TPA

A

Third party administrator

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9
Q

PCI

A

Pharmacy incentive program

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10
Q

OTC

A

Over the counter

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11
Q

OPP

A

Out of pocket

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12
Q

Daw2

A

Dispense as written

Member wants this one

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13
Q

P&T

A

Pharmacy and Therapeutic

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14
Q

PHI

A

Personal health information

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15
Q

FAC

A

Formulary advisory committee

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16
Q

ST

A

Step therapy

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17
Q

GW

A

Generic waver program

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18
Q

RxCents

A

Tablet spitting program

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19
Q

EOB

A

Explanation of Benefits

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20
Q

HIPAA

A

Health insurance portability and Accountability Act

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21
Q

BIN

A

Benefit identification number

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22
Q

DUR

A

Drug Utilization Report

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23
Q

EGWP

A

Employer Group Waiver Plan

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24
Q

MAC

A

Manage Care Options

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25
Q

NAP

A

Non-automated PA

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26
Q

NPD

A

Non-Preferred Drug

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27
Q

NPI

A

National provider identifier

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28
Q

PCN

A

Process Control Number

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29
Q

PDL

A

Preferred Drug list

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30
Q

PHI

A

Personal (Protective/Patient) Health information

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31
Q

Elig.

A

Eligibility

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32
Q

ETC

A

Exception to Coverage

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33
Q

ST

A

Step therapy

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34
Q

PHI

A

Personal health information

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35
Q

PCG

A

Program component guides

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36
Q

TSF

A

Telephone service factor

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37
Q

ASTS

A

Average speed to answer

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38
Q

CCD

A

Customer care dashboard

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39
Q

PCG’s

A

Program component Guide

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40
Q

POA

A

Power of attorney this must be medical

We must have a copy of medical power of attorney on file

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41
Q

Formulary

A

Is the preferred drug list that limits the number of drugs available with in a therapeutic class for drug purchasing, dispensing and or reimbursement

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42
Q

Therapeutic class

A

Is a drug group used to treat the same illness like cholesterol lowering, antidepressants and Blood pressure

43
Q

Formulary

A

A preferred drug list that limits the number of drugs available within the therapeutic class for drug purchasing dispensing and or reimbursement

44
Q

Therapeutic class

A

This is a group of medications the treat the same illness like
cholesterol lowering
antidepressants
blood pressure etc.

45
Q

Formulary as a thing

A

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
Q

Formulary as status

A

This is the level or tear of the drugs covered on the benefit

47
Q

Drugs are either formulary or non-formulary

A 
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
Q

P&T committee

A

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
Q

The (P&T Committee) pharmacy & therapeutic committee
Drug products are evaluated on four criteria in order
what are they?

A

Effectiveness
Side - effects
Drug interactions
Value the cost

50
Q

FDA

A

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
Q

How long does a drug need to be on the market before a (P&T) committee will consider it.

A

6 months

52
Q

Rebates are sought for preferred drugs

What does this determined

A

This determines which of two equally effective drugs become preferred

53
Q

PCP

A

Primary care physicians

54
Q

FAC

A

Formulary advisory committee

55
Q

Who does FAC include

A

Navitus clinical staff and non-Navitus members

56
Q

What does the FAC group do

A

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
Q

Tell me about brand name

A

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
Q

Tell me about Generic drugs

A

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
Q

Some clients use a tier and some use space level placement

What do they mean?

A

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
Q

What is traditional formulary?

A

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
Q

What is the select formulary?

A

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
Q

What is Open formulary?

A

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
Q

What is managed formulary?

A

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
Q

QRF

What does QRS mean?

A

(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
Q

Searching a formulary

A 
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
66
Q

There are two general orders of search results for drug names what are they?

A
  1. Alphabetical Index list

2. Chapters (therapeutic class)

67
Q

There are two general order of search results for medications one is alphabetical Index list what information does this give you.

A

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
Q

There are two general orders for medications one is sorted by chapters (therapeutic class). What information does this give you?

A

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
Q

F

A

= formulary covered

70
Q

NC

A

= not covered

71
Q

B

A

Brand

72
Q

G

A

Generic

73
Q

TS or cents sign means

A

Drug is on the RxCents (tablet splitting) program

74
Q

PA

A

Prior authorization

Drug requires prior authorization before it will be covered.

75
Q

NP

A

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
Q

PA* or (Tier)*

A

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
Q

SP

A

Specialty pharmacy

Drug is available through a specialty pharmacy (voluntary).

78
Q

MSP

A

Mandatory specialty pharmacy

Members are required to get the drug through a specialty pharmacy.

79
Q

QL

A

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
Q

RS

A

Restricted to specialist

81
Q

GW

A

Generic waiver program the co-pay on the first Month is always free

82
Q

VAC

A

Drug is part of the vaccination program (listed along with applicable copay).

83
Q

NM

A

Drug is not available through mail order

84
Q

A rate

What does this mean?

A

This means that the generic is interchangeable with the brand-name. Pharmacist can interchange this without approval from the doctor.

85
Q

B rate

What does this mean?

A

This means that The generic is not considered interchangeable so pharmacies can only substitute this generic for Brand product with physician approval

86
Q

FBMS

A

Formulary and benefit management system

87
Q

FBMS

A

Formulary and Benefits Management System

88
Q

PAR

What do the letters stand for?

A

Participating pharmacy

89
Q

PAR

What is the definition?

A

Participating pharmacy means

A pharmacy who has signed a contract agreeing to Navitus reimbursement terms.

90
Q

MO

What do the letters stand for?

A

Mail order

91
Q

MO

What is the definition?

A

Mail order

Is the pharmacy but only meals medications.

92
Q

SP

What does the letter stand for?

A

Specialty pharmacy

93
Q

SP

What is the definition?

A

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
Q

HCRC

What do the letters mean?

A

Health care reform contraceptives

This list can be found under
reference documents forms

95
Q

DMS

What do the letters stand for?

A

Disposal medical supplies

96
Q

DMS

What does this mean

A

Disposal medical supplies

Means that items used ones and discarded are covered

97
Q

DME

What do the letters stand for?

A

Durable medical equipment

98
Q

DME

What is the definition?

A

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
Q

Refill rules

A

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
Q

Forgotten meds

A

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
Q

Replacement meds

A

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
Q

Vacation

A

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
Q

HDHP

What do the letters stand for?

A

High deductible health plans.

103
Q

Discount RX card

A

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.

Member Services Abbreviations (4 decks)

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