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
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.
Retrospective review
A type of formulary that allows plan enrollees to have any covered prescription drugs prescribed for them
Open formulary
A type of formulary that encourages the use of certain drugs in return for a reduced payment
Preferred formulary
A type of formulary where the plan will not cover a nonformulary drug
Closed formulary
A program that measures/manages all healthcare outcomes and costs associated with a particular disease across the entire continuum of healthcare delivery.
Disease state management program
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
Medical model
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.
Therapy-directed model
An approach to medical decision making that emphasizes scientific evidence and statistical methods for evaluating outcomes and risk of treatments
Evidence-based medicine
An entity that administers managed pharmacy programs through application of programs, services, and techniques designed to control costs.
Pharmacy benefit manger (PBM)
An agreement between a pharmacy benefit manager and a drug manufacturer to secure significant reductions in the cost of prescription drugs.
Rebate
Prior generation of prescription drug plans
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
Carve-out plan
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
Average wholesale price (AWP)
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
Wholesale acquisition cost (WAC)
The price of a drug at which wholesalers buy pharmaceuticals from manufacturers
Maximum allowable cost (MAC)
Set by the Medicaid program, this is the upper price limit for all generic medications
Copay
A predetermined amount a participant pays when a prescription is filled
Exclusion
A special classification of medications not covered by a plan
Lifestyle drugs
Prescription products that don’t cure illness, but improve daily life by enhancing psychological attitudes, energy levels, sexual performance, or body image.
Over the counter (OTC) drugs
Types of medications that do not require a prescription and can simply be purchased at the drug store.
Biotechnology medications
Drugs made from living cells that treat various diseases.
Prospective review
A type of drug utilization program for educating physicians about drugs or drug therapies
Formulary
A list of drugs preferred by a health plan/pharmacy benefits manager
Prior Authorization
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.
Quantity limits
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.
Concurrent review
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.
Retrospective review
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.
Open formulary
A type of formulary that allows plan enrollees to have any covered prescription drugs prescribed for them
Preferred formulary
A type of formulary that encourages the use of certain drugs in return for a reduced payment
Closed formulary
A type of formulary where the plan will not cover a nonformulary drug
Disease state management program
A program that measures/manages all healthcare outcomes and costs associated with a particular disease across the entire continuum of healthcare delivery.
Medical model
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
Therapy-directed model
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.
Evidence-based medicine
An approach to medical decision making that emphasizes scientific evidence and statistical methods for evaluating outcomes and risk of treatments
Pharmacy benefit manger (PBM)
An entity that administers managed pharmacy programs through application of programs, services, and techniques designed to control costs.
Rebate
An agreement between a pharmacy benefit manager and a drug manufacturer to secure significant reductions in the cost of prescription drugs.
