Module 6 Flashcards
(25 cards)
A type of prescription
drug benefit plan
embedded in a major
medical plan where the
participant paid in full
and then, filed a claim
for reimbursement
Prior generation of
prescription drug plans
A type of prescription
drug plan that is typically
administered by a
pharmacy benefit
manager or a third-party
administrator apart from
the medical plan
Carve-out plan
The price of a drug
assigned by the drug
manufacturer and used
as a reference price for
all discounts paid to
pharmacies and
pharmacy benefit
managers
Average wholesale
price (AWP)
The price of a drug
at which wholesalers
buy
pharmaceuticals
from manufacturers
Wholesale acquisition
cost (WAC)
Set by the
Medicaid
program, this is the
upper price limit
for all generic
medications
Maximum allowable
cost (MAC)
A predetermined
amount a
participant pays
when a
prescription is filled
Copay
A special
classification of
medications not
covered by a plan
Exclusions
Prescription products that
don’t cure illness, but
improve daily life by
enhancing psychological
attitudes, energy levels,
sexual performance, or
body image.
Lifestyle drugs
Types of medications
that do not require a
prescription and can
simply be purchased at
the drug store.
Over the counter (OTC)
drugs
Drugs made from
living cells that
treat various
diseases.
Biotechnology
medications
A type of drug
utilization program
for educating
physicians about
drugs or drug
therapies
Prospective review
A list of drugs
preferred by a
health plan/
pharmacy
benefits
manager
Formulary
A program that restricts
coverage for certain
drugs based on the
patient’s conditions and
maximizes the outcome
of the medication. The
physician must call in to
the plan administrator.
Prior authorization
A predefined
maximum quantity for
specific medications
that restricts the
number of dosage
units. It may be used
to prevent abuse or
overuse of the
medication.
Quantity limits
A drug utilization
program that occurs at
the point of service and
flags potential overuse
based on clinical
monitoring criteria or
‘edits’ programmed into
the pharmacy benefit
manager’s system.
Concurrent review
A drug utilization
program that requires
the pharmacist or nurse
to review the patient
profile to determine if
they are complying with
drug therapy or to
suggest alternative
therapies.
Retrospective review
A type of formulary
that allows plan
enrollees to have any
covered prescription
drugs prescribed for
them
Open formulary
A type of formulary
that encourages
the use of certain
drugs in return for
a reduced
payment
Preferred formulary
A type of
formulary where
the plan will not
cover a nonformulary drug
Closed formulary
A program that
measures/manages all
healthcare outcomes
and costs associated
with a particular disease
across the entire
continuum of healthcare
delivery.
Disease state
management program
A type of disease state
management program
that uses call centers
staffed by nurses to
triage patients with
select diseases to
appropriate levels of
care and to follow up
with them
Medical model
A type of disease state
management program
administered by PBMs,
pharmaceutical
manufacturers, or health
plans to improve
compliance with
medication therapy,
educate patients, and test
outcomes
Therapy-directed
model
An approach to
medical decision
making that
emphasizes scientific
evidence and
statistical methods for
evaluating outcomes
and risk of treatments.
Evidence-based
medicine
An entity that
administers managed
pharmacy programs
through application of
programs, services,
and techniques
designed to control
costs.
Pharmacy benefit
manager (PBM)
