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MODULE 9: KEY TERMS
Managed care prescriptions
| Question | Answer |
|---|---|
| Adjudication: | Third-party insurance approval process. |
| Audit: | A formal examination of an organization to verify accounts. |
| Average Acquisition Cost: | Average cost the pharmacy pays for drugs from a wholesaler. |
| Average Manufacturer Price: | Average price a wholesaler pays the manufacturer for drugs (for retail pharmacies only). |
| Average Wholesale Price: | A price used for pharmacy pricing and reimbursement from insurance payers. |
| Bank Identification Number: | Six-digit number on an insurance card that the pharmacy uses to identify which insurance provider should receive the claim. |
| Bioequivalent: | Medication that releases its active ingredient at the same rate and in the same amounts as the original medication to produce the same blood levels of the medication. |
| Claims Reconciliation: | The process of comparing claims submissions to claims payments to detect incorrect claims rejections, underpayments, or overpayments. |
| Deductible: | A form of patient cost-sharing. The amount that must be inccured and paid by the patient during a specified time period before benefits are paid by the insurance company. |
| Direct Acquisition Cost: | Cost to the pharmacy for direct purchases (from a manufacturer other than the pharmacy wholesaler). |
| Drug Utilization Review: | A process in which patterns of prescribing, dispensing, and using prescription medications are monitored. May be prospective or retrospective. |
| Estimated Acquisition Cost: | Estimated price that state Medicaid programs use for pharmacy reimbursement. |
| Group Number: | A set of numbers or letters (or combination of both) that identifies the specific benefits plan for the member. |
| Maximum Allowable Cost: | The maximum amount that an insurance provider or PBM will pay or generic medications (or brand-name medications with generic available). |
| Multiple-Source Generic Medications: | A medication that has a generic form available. |
| National Average Drug Acquisition Cost: | An average of medication acquisition costs from retail pharmacies. |
| Out-Of-Pocket Expenses: | Medical expenses that are not covered by insurance . They may include copayments, deductible, and coinsurance. |
| Pharmaceutical Equivalents: | Medication that have the same active ingredients, dosage form, route of adminstration, and strength as another medication. They may differ with regard to shape, color, packaging, and inactive ingredients. |
| Pharmacy Benefit Manager: | Specializes in the management of the prescription portion of a managed health care plan. PBMs contract with participating pharmacies , process claims, control costs, and manage the various elements of the pharmacy benefit. |
| Prior Authorization: | A requirement that specific medications be covered only if approved by the third-party payer. Usually prescribers or pharmacists must certify that the medication is medically necessary and superior to less costly alternatives before approval is given. |
| Processor Control Number: | A numerical identifier on an insurance card that may be used to route prescription claims. |
| Remittance Advice: | An electronic transaction that provides claim payment information and is used to post information into a pharmacy or health care system. |
| Therapeutic Equivalent: | Medications that are pharmaceutical equivalents and have the same clinical effect and safety profile. |
| Third-Party Programs: | Private health benefit programs and government-run programs t pay for prescriptions on behalf of patients. |
| Wholesale Acquisition Cost: | The list price set by manufacturers for wholesalers. |
Created by:
tyshawnm_jobcorps
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