*New! Formulary Terms

Question 1

Formulary

Answer 1

Documented list of drug names accessed to quote details on products that are covered, not covered, and covered at a less than optimum rate. No two formularies are alike. Each formulary is uniquely tailored to the client’s needs and organized by therapeutic classes.

Question 2

Therapeutic Class

Answer 2

A therapeutic class is a drug group used to treat the same illness or medical condition.

Question 3

Brand

Answer 3

Adrugthat is formulated, developed, and sold by adrugcompany under a specificnameor trademark and that is protected by a patent.

Question 4

Generic

Answer 4

Once a Brand patent has expired, the formulation becomes public and may be produced by other manufacturers. Generics take the chemical name of the parent Brand product.

Question 5

P&T Committee

Answer 5

A group of volunteer medical professionals who review medications to determine if they should be covered on formularies in comparison to currently-covered products. They establish criteria for patient use, make recommendations for patient financial responsibility, and review coverage criteria annually.

Question 6

Clinical Pharmacists

Answer 6

Clinical pharmacyis a health science discipline in whichpharmacistsprovide patient care that optimizes medication therapy and promotes health, and disease prevention.

Question 7

Side effect

Answer 7

A secondary, typically undesirable effect of a drug or medical treatment. (I.e. Using Pepto Bismol will turn your tongue black due to a chemical reaction.) Offer to connect members to Navitus Clinical Pharmacists to discuss side effects or drug interactions.

Question 8

Drug interaction

Answer 8

A drug interaction is a change in the action or side effects of a drug caused by administration with a food, beverage, supplement, or another drug. There are many causes of drug interactions. For example, one drug may alter the strength of another. Offer to connect members to Navitus Clinical Pharmacists to discuss side effects or drug interactions.

Question 9

MediSpan

Answer 9

The most widely used databank of drug information; Navitus receives weekly updates to our NaviClaim software (Tuesday). Information supplied includes the manufactuerer, how a drug is administered, whether it’s a controlled substance, how it’s packaged, the chemical name, whether is available over-the-counter or is prescription-only, etc.

Question 10

Maintenance

Answer 10

A medication designated as ‘maintenance’ by MediSpan is taken over long periods of time to stabilize/control a disease state.

Question 11

NDC

Answer 11

Drugproducts are identified using a unique, 11 digit number called theNational Drug Code(NDC), which serves as a universal product identifier.

Question 12

GPI

Answer 12

The Generic Product Identifier (GPI) is a 14-character number that identifies the therapeutic class of a medication, and encompasses all NDCs for products in that therapeutic class.

Example: A GPI is the tree in which NDC-leaves grow. All the leaves belong to the same tree, though each leaf represents a different strength, manufacturer, form, or packaging for a product in that class. NSAIDS are the tree, ibuprofen 200mg tab, Advil EC tabs, ibuprofen 200mg gelcaps, ibuprofen 800mg tabs, Motrin 200mg tab, etc. are the leaves.

Question 13

Are brand medications better quality than generics?

Answer 13

No, generics should produce the same clinical results as the brand. They have the same active ingredient, delivered to the body at the same time, and used by the body in the same way as the brand.

Question 14

What’s the difference between brand and generics?

Answer 14

The shape (fillers), color (dyes) and coatings (buffers). Think of brand and generic “couples” as identical twins. Identical DNA, but appearance may vary (hair color, dress differently, etc.).

Question 15

Copay

Answer 15

The member’s responsibility is a flat dollar amount (I.e. $0, $10, 50, etc.).

Question 16

Coinsurance

Answer 16

The member’s responsibility is a percentage of cost (I.e. 20%, 40%, 75%, etc.).

Question 17

Tier or Level

Answer 17

Tiers or Levels identify the patient responsibility on the formulary in the form of a number, letter, percentage or dollar amount.

Question 18

Utilization tools

Answer 18

Restrictions placed on a medication such as Quantity Limit, Step Therapy, Prior Authorization, Mandatory Specialty Pharmacy use, etc. See Brainscape Deck: “Drug Edits” for more on Utilization Tools.

Question 19

Medications must be FDA approved and available to the public for _______ before the P&T Committee will review them for coverage.

Answer 19

6 months; the P&T Committee wants to ensure safety with the larger public before reviewing medications for coverage on formularies.

Question 20

Effectiveness

Answer 20

How well a drug treats the intended disease state.

Question 21

TAB

Answer 21

Tablet

Question 22

CAP

Answer 22

Capsule

Question 23

POW or GRA

Answer 23

Powder or Granule; to be mixed in juice or with food

Question 24

OINT

Answer 24

Ointment

Question 25

OPTH

Answer 25

Ophthalmic; a solution or ointment intended to treat eyes. Ophthalmic products may occasionally be used to treat ears as a secondary indication.

Question 26

NEB

Answer 26

Nebulized medication; a nebulizer is a drug delivery device used to administer medication in the form of a mist inhaled into the lungs. Nebulizers are commonly used for the treatment of asthma, cystic fibrosis, COPD and other respiratory diseases or disorders.

Question 27

SYP

Answer 27

Syrup

Question 28

SOL or SOLN

Answer 28

Solution

Question 29

SUS

Answer 29

Suspension

Question 30

INJ

Answer 30

Injectible

Question 31

PAK

Answer 31

A foil bubble-pack of medication (I.e. Azithromycin “Z-PAK” or oral contraceptives)

Question 32

CHW

Answer 32

Chewable

Question 33

DR

Answer 33

Delayed Release; releases in the body at a specific point, often the small intestine.

Question 34

DIS

Answer 34

Patch (I.e. nicotine patch, Fentanyl patch)

Question 35

CR

Answer 35

Cream

Question 36

ODT

Answer 36

Oral Disintegrating Tablet

Question 37

LOZ

Answer 37

Lozenge (I.e. pain medication or cough drop)

Question 38

SR, ER, LA, CR, XR, XL (all synonymous)

Answer 38

Sustained release
Extented release
Long acting
Controlled release
Extended release
Extended length

Question 39

IM

Answer 39

Intramuscular; as in an injection that is administered in the muscle. IM injections are typically given by a medical professional but could be covered by the pharmacy benefit – see the client-specific CCG Product Table regarding Injectibles for rules.

Question 40

IV

Answer 40

Intraveneous; medication that is administered intraveneously is not typically a pharmacy benefit because it requires the aid of a medical professional. Certain plans may cover IV medications, also called infusions. Example: LA Care Infusion formulary.

Question 41

SC

Answer 41

Subcutaneous; medications that members administer under the skin (subcutaneous) are typically a pharmacy benefit. Example: Diabetic insulin, EpiPen, etc.