PTCB - Chapter 14 - Financial Issues - Definitions

Pharmacy benefit managers
- companies that administer drug benefit programs

Online adjudication
- the resolution of prescription coverage through  the communication of the pharmacy computer with the third party computer

Co-insurance
- an agreement for cost sharing between the insurer and the insured

Co-pay
- the portion of the price of medication that the patient is required to pay

Maximum allowable cost (MAC)
- the maximum price per tablet (or other dispensing unit) an insurer or PBM will pay for a given product

Usual and customary (U&C) or (UCR) usual, customary, reason
- the maximum amount of payment for a given prescription, determined by the insurer to be a usual and customary (and reasonable) price

Dual co-pay
- co-pays that have two prices: one for generic and one for brand medications

Deductible
- a set amount that must be paid by the patient for each benefit period before the insurer will cover additional expenses

Prescription drug benefit cards
- cards that contain third party billing information for prescription drug purchases

Formulary
- a list of medications covered by third party plans

Tier
- categories of medications that are covered by third party plan

HMO
-  a network of providers for which costs are covered inside but not outside of the network

POS
- a network of providers where the patient's primary care physician must be a member and costs outside the network may be partially reimbursed

PPO
- a network of providers where costs outside the network may be partially reimbursed and the patient's primary care physician need not be a member

Medicare
- a federal program providing health care to people with certain disabilities or who are over age 65; it includes basic hospital insurance, voluntary medical insurance, and voluntary prescription drug insurance

Medicaid
- a federal-state program, administered by the states, providing  health care for the needy

Workers' compensation
- an employer compensation program for employees accidentally injured on the job

Patient assistance program
- manufacturer sponsored prescription drug programs for the needy

Online Claim Information
1) cardholder identification number; group number
2) patient name; birth date; sex (M or F)
3) relationship to cardholder
4) date Rx written; date Rx dispensed; new/refill prescription
5) national drug code (NDC) of drug;  DAW indicator
6) amount/quantity dispensed; days supply
7) identification number of prescribing physician
8) identification of pharmacy/National Provider Identification (NPI)
9) ingredient cost; dispensing fee; total price
10) deductible or co-pay amount; balance due

DAW Indicators
-- typical
       0 = No DAW (No Dispense As Written)
       1 = DAW handwritten on prescription by prescriber
       2 = Patient requested brand
-- not typical
       3 = Pharmacist selected brand
       4 = Generic not in stock
       5 = Brand name dispensed but priced as generic
       6 = n/a
       7 = Substitution not allowed; brand mandated by law
       8 = Generic not available
       9 = Other

Universal Claim Form (UCF)
- a standard claim form accepted by many insurers

CMS-1500 form
- the standard form used by health care providers to bill for services, including disease state management services

Medication Therapy Management (MTM) services
- services provided to some Medicare beneficiaries who are enrolled in Medicare Part D and who are taking multiple medications or have certain disease

Prescription Drug Plans (PDPs)
- third party programs for Medicare Part D

National Provider Identifier (NPI)
- the code assigned to recognized health care providers; needed to bill MTM services

CMS-10114 form
- the standard six page form used by health care providers to apply for a national provider identifier (NPI)

Current Procedural Terminology codes (CPT codes)
- identifiers used for billing pharmacist-provided MTM services