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chap 15
| Question | Answer |
|---|---|
| co-insurance | an agreement for cost-sharing between the insurer and the insured |
| co-pay | the portion of the medications price that the patient is required to pay |
| dual co-pay | co-pays that have two prices: one for generic and one for brand medications |
| maximum allowable cost(MAC) | the maximum price per tablet (or other dispensing unit) an insurer or PBM will pay for a given product |
| online adjudication | the resolution of prescription coverage through the communication of the pharmacy computer with the third party computer |
| pharmacy benefit managers | companies that administer drug benefit program |
| UCR | the maximum amount of payment for given prescription, determined by the insurer to be a usual and customary (and reasonable) price |
| deductible | a set amount that must be paid by the patient for each benefit period before the insurer will cover additional expenses |
| formulary | a list of medications covered by third-party plans |
| prescription drug benefit cards | cards that contain third-party billing information for prescription drug purchases |
| tier | categories of medications that are covered by third-party plans |
| HMO | costs are covered only for services from in-network providers |
| POS | the patients primary care physician must be a member; and cost outside the network may be partially reimbursed |
| PPO | costs outside the network may be partially reimbursed and the patients primary care physician need mot be a member |
| medicaid | a federal state program, administered by the states, providing health care for the needy |
| medicare | a federal program providing health care to people with certain disabilities or who are over 65 |
| patient assistance program | manufacturer sponsored prescription drug programs for the needy |
| workers compensation | an employer compensation program for employees accidentally injured on the job |
| prior authorization | a procedure to gain third-party coverage for a drug that is not automatically covered by a third-party plan |
| CMS-1500 form | the standard form used by health care providers to bill for services, including disease state management services |
| universal claim form (UCF) | a standard claim form accepted by many insurers |
| 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 |
| 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 diseases |
| National provider identifier (NPI) | the code assigned to recognized health-care providers; needed to bill MTM services |
| Prescription drug plans(PDPs) | third-party programs for Medicare Part D |
Created by:
laylaoxendine
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