Module 6 Flashcards
A type of prescription drug benefit plan embedded in a major medical plan where the participant paid in full and then, filed a claim for reimbursement
Prior generation of prescription drug plans
A type of prescription drug plan that is typically administered by a pharmacy benefit manager or a third-party administrator apart from the medical plan
Carve-out plan
The price of a drug assigned by the drug manufacturer and used as a reference price for all discounts paid to pharmacies and pharmacy benefit managers
Average wholesale price (AWP)
The price of a drug at which wholesalers buy pharmaceuticals from manufacturers
Wholesale acquisition cost (WAC)
Set by the Medicaid program, this is the upper price limit for all generic medications
Maximum allowable cost (MAC)
A predetermined amount a participant pays when a prescription is filled
Copay
A special classification of medications not covered by a plan
Exclusion
Prescription products that don’t cure illness, but improve daily life by enhancing psychological attitudes, energy levels, sexual performance, or body image.
Lifestyle drugs
Types of medications that do not require a prescription and can simply be purchased at the drug store.
Over the counter (OTC) drugs
Drugs made from living cells that treat various diseases.
Biotechnology medications
A type of drug utilization program for educating physicians about drugs or drug therapies
Prospective review
A list of drugs preferred by a health plan/pharmacy benefits manager
Formulary
A program that restricts coverage for certain drugs based on the patient’s conditions and maximizes the outcome of the medication. The physician must call in to the plan administrator.
Prior Authorization
A predefined maximum quantity for specific medications that restricts the number of dosage units. It may be used to prevent abuse or overuse of the medication.
Quantity limits
A drug utilization program that occurs at the point of service and flags potential overuse based on clinical monitoring criteria or ‘edits’ programmed into the pharmacy benefit manager’s system.
Concurrent review