Reimbursement Terms

Question 1

Actual Acquisition Cost (AAC)

Answer 1

the real cost paid to obtain a drug/ purchase price

Question 2

Adjudication

Answer 2

processing a claim to determine an appropriate payment (done electronically, what will you cover)

Question 3

Carrier

Answer 3

Insurance company insuring the plan or providing administration services

Question 4

Copayment

Answer 4

a set dollar amount applied to each individual rx dispensed that the patient is responsible for paying

Question 5

Deductible

Answer 5

set dollar amount that must be paid by the patient before coverage of health benefits start (annual and don’t always follow calendar year)

Question 6

Dispensing Fee Cap

Answer 6

the plan sponsor may opt to only pay a fixed dollar value towards dispensing fee, patient pay difference (not always)

Question 7

Intervention Code

Answer 7

override code which corresponds with a reason why this med is being dispensed despite the warning

Question 8

Lowest cost alternative

Answer 8

lowest unit cost established for a drug within a set of interchangeable generics

Question 9

Preferred Pharmacy Network

Answer 9

employers may decide to have their members’ rxs filled from certain pharmacies or chains