Pharmacy Billing Flashcards
Formulary
A list of preapproved medications that are covered under a prescription plan or within an institution
Pharmacy and Therapeutics Committee (P&T committee)
Medical staff composed of physicians, pharmacists, pharmacy technicians, nurses, and dietitians who provide necessary information and advice to the institution or insurer on whether a drug should be added to a formulary
Open Formulary
A formulary list that is essentially unrestricted in the types of drug choices offered or that can be prescribed and reimbursed under the health provider plan or pharmacy benefit plan
Closed Formulary
Tight restriction of medication use to the medications included on the formulary list; medications that are not listed as preapproved drugs per the health plan provider or pharmacy benefits manager are not reimbursed except under extenuating circumstances and with proper documentation
Drug Utilization Evaluation
An ongoing review by a pharmacist of the prescribing, dispensing, and use of medications, based on predetermined criteria, to decide whether changes need to be made in a patient’s drug therapy
Copayment
The portion of the prescription bill that the patient is responsible for paying
Coinsurance
A type of insurance in which the insured pays a share of the payment of the medication after paying the deductible to the insurance, who covers the rest
Health Maintenance Organization (HMO)
An insurance plan that allows coverage for in-network only physicians and services and uses the primary care physician (or provider) as the “gatekeeper” for the patient’s health care; patients often have co-pays to defray the costs of medical care and prescription drugs
Adjudication
Electronic insurance billing for medication payment
Prior Authorization
Insurance-required approval for a restricted, non-formulary, or non-covered medication before a prescription medication can be filled
Preferred Provider Organization (PPO)
An insurance plan in which patients choose a provider from a specified list, resulting in reduced costs for medical services
Deductible
Amount paid by a policyholder out of pocket before the patient is responsible for paying
Medicaid
A government-managed insurance program that provides health care services to low-income children, the elderly, and children with disabilities
Medicare
A government-managed insurance program composed of several coverage plans for health care services and supplies; it is funded by both federal and state entities, and individuals must meet specific requirements to be eligible; individuals must be 65 years or older, be younger than 65 with long-term disabilities, or have end-stage renal disease
Medicare Modernization Act (MMA)
The enactment of prescription drug coverage provided for individuals covered under Medicare
