*New! Formulary Terms Flashcards
Formulary
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.
Therapeutic Class
A therapeutic class is a drug group used to treat the same illness or medical condition.
Brand
Adrugthat is formulated, developed, and sold by adrugcompany under a specificnameor trademark and that is protected by a patent.
Generic
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.
P&T Committee
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.
Clinical Pharmacists
Clinical pharmacyis a health science discipline in whichpharmacistsprovide patient care that optimizes medication therapy and promotes health, and disease prevention.
Side effect
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.
Drug interaction
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.
MediSpan
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.
Maintenance
A medication designated as ‘maintenance’ by MediSpan is taken over long periods of time to stabilize/control a disease state.
NDC
Drugproducts are identified using a unique, 11 digit number called theNational Drug Code(NDC), which serves as a universal product identifier.
GPI
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.
Are brand medications better quality than generics?
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.
What’s the difference between brand and generics?
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.).
Copay
The member’s responsibility is a flat dollar amount (I.e. $0, $10, 50, etc.).
Coinsurance
The member’s responsibility is a percentage of cost (I.e. 20%, 40%, 75%, etc.).
Tier or Level
Tiers or Levels identify the patient responsibility on the formulary in the form of a number, letter, percentage or dollar amount.
Utilization tools
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.
Medications must be FDA approved and available to the public for _______ before the P&T Committee will review them for coverage.
6 months; the P&T Committee wants to ensure safety with the larger public before reviewing medications for coverage on formularies.
Effectiveness
How well a drug treats the intended disease state.
TAB
Tablet
CAP
Capsule
POW or GRA
Powder or Granule; to be mixed in juice or with food
OINT
Ointment
OPTH
Ophthalmic; a solution or ointment intended to treat eyes. Ophthalmic products may occasionally be used to treat ears as a secondary indication.
NEB
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.
SYP
Syrup
SOL or SOLN
Solution
SUS
Suspension
INJ
Injectible
PAK
A foil bubble-pack of medication (I.e. Azithromycin “Z-PAK” or oral contraceptives)
CHW
Chewable
DR
Delayed Release; releases in the body at a specific point, often the small intestine.
DIS
Patch (I.e. nicotine patch, Fentanyl patch)
CR
Cream
ODT
Oral Disintegrating Tablet
LOZ
Lozenge (I.e. pain medication or cough drop)
SR, ER, LA, CR, XR, XL (all synonymous)
Sustained release Extented release Long acting Controlled release Extended release Extended length
IM
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.
IV
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.
SC
Subcutaneous; medications that members administer under the skin (subcutaneous) are typically a pharmacy benefit. Example: Diabetic insulin, EpiPen, etc.
