Module 6 Flashcards

1
Q

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

A

Prior generation of prescription drug plans

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2
Q

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

A

Carve-out plan

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3
Q

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

A

Average wholesale price (AWP)

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4
Q

The price of a drug at which wholesalers buy pharmaceuticals from manufacturers

A

Wholesale acquisition cost (WAC)

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5
Q

Set by the Medicaid program, this is the upper price limit for all generic medications

A

Maximum allowable cost (MAC)

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6
Q

A predetermined amount a participant pays when a prescription is filled

A

Copay

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7
Q

A special classification of medications not covered by a plan

A

Exclusion

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8
Q

Prescription products that don’t cure illness, but improve daily life by enhancing psychological attitudes, energy levels, sexual performance, or body image.

A

Lifestyle drugs

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9
Q

Types of medications that do not require a prescription and can simply be purchased at the drug store.

A

Over the counter (OTC) drugs

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10
Q

Drugs made from living cells that treat various diseases.

A

Biotechnology medications

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11
Q

A type of drug utilization program for educating physicians about drugs or drug therapies

A

Prospective review

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12
Q

A list of drugs preferred by a health plan/pharmacy benefits manager

A

Formulary

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13
Q

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.

A

Prior Authorization

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14
Q

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.

A

Quantity limits

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15
Q

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.

A

Concurrent review

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16
Q

A drug utilization program that requires the pharmacist or nurse to review the patient profile to determine if they are complying with drug therapy or to suggest alternative therapies.

A

Retrospective review

17
Q

A type of formulary that allows plan enrollees to have any covered prescription drugs prescribed for them

A

Open formulary

18
Q

A type of formulary that encourages the use of certain drugs in return for a reduced payment

A

Preferred formulary

19
Q

A type of formulary where the plan will not cover a nonformulary drug

A

Closed formulary

20
Q

A program that measures/manages all healthcare outcomes and costs associated with a particular disease across the entire continuum of healthcare delivery.

A

Disease state management program

21
Q

A type of disease state management program that uses call centers staffed by nurses to triage patients with select diseases to appropriate levels of care and to follow up with them

A

Medical model

22
Q

A type of disease state management program administered by PBMs, pharmaceutical manufacturers, or health plans to improve compliance with medication therapy, educate patients, and test outcomes.

A

Therapy-directed model

23
Q

An approach to medical decision making that emphasizes scientific evidence and statistical methods for evaluating outcomes and risk of treatments

A

Evidence-based medicine

24
Q

An entity that administers managed pharmacy programs through application of programs, services, and techniques designed to control costs.

A

Pharmacy benefit manger (PBM)

25
Q

An agreement between a pharmacy benefit manager and a drug manufacturer to secure significant reductions in the cost of prescription drugs.

A

Rebate