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C13
| Question | Answer |
|---|---|
| Adjudication | Electronic insurance billing for medication payment |
| Average Wholesale Price (AWP) | The average price at which a drug is sold, the data are compiled for information provided by manufactures, distributors, and pharmacies. the AWPM is often used in calculations related to medication reimbursement |
| Civilian Health and Medical Program of Department of Veterans Affairs (CHAMPVA) | A program for veterans with permanent service-related disabilities and their dependents for the spouses and children of veterans who died of service-connected disability; also known as Veterans Health Administration (VHA) |
| Closed Formulary | Tight restriction of medication uses to medications included on the formulary list; medications that are no listed as preapproved drugs per the health plan provider or pharmacy benefits manager are not reimbursed except under extenuating circumstances |
| Copayment | The portion of the prescription bill that the patient is responsible for paying |
| Deductible | The amount paid by a policyholder out of pocket before the insurance company pays the claim |
| Direct manufacturer ordering | Pharmacies may join a group of purchasing organization and contract directly with the manufacturer to obtain better pricing |
| Drug utilization evaluation (DUE) or review (DUR) | An ongoing review by a pharmacist of the prescribing, dispensing, and use of the medications, based on predetermined criteria, to decide whether changed need to be made in a patient's drug therapy |
| Formulary | A list of preapproved medications that are covered under a prescription plan or within an institution |
| Health Insurance Portability and Accountability Act (HIPPA) | Federal guidelines for the protection of a patients personal health information |
| Inventory | The amount of product a pharmacy has for sale |
| Just-in-time ordering | A system that orders a product just before its sold. |
| Medicaid | A government-managed insurance program that provides health care services to low-income children, elderly, the blind, and those with disabilities |
| Medicare | A government-managed insurance program composed of several coverage programs for health care service and supplies. 65 and older, be younger then 65 with disabilities and have end-stage renal disease. |
| Medicare Modernization Act (MMA) | The enactment of prescription drug coverage provided for individuals covered under Medicare |
| Medigap plan | Supplemental insurance provided through private insurance companies to help cover the cost not reimbursed by the Medicare plan, such as coinsurance, copays and deductibles |
| National Drug Code (NDC) | A 10-digit number given to al drugs for identification purposes, in health care and drug databases, the NDC is represented as an 11-digit number in which the place holder zeros are inserted in proper order in the code for standardizing data transmissions |
| National Provider Identifier (NPI) | A number associated to any health care provider that is used for the purpose of standardizing health data transmissions |
| Open Formulary | A formulary list that is essentially unrestricted in the types of drug choices offered or that can be prescribed and reimbursed under the health provider plan or pharmacy benefit plan |
| Patient Profile | A document listing necessary patient personal health information, including comprehensive information on the medications that patient is taking, disease states, and any food or drug allergies the person might have. |
| Periodic Automatic replenishment | The PAR of stock levels to a certain number of allowed units |
| Pharmacy and Therapeutics committee (P&T committee) | Medical staff composed of physicians, pharmacists, pharmacy technicians, nurses, and dieticians who provide necessary information and advice to the institution or insurer on whether should be added to the formulary |
| Point of sale (POS) | A system that allows inventory to be tracked as it is used. |
| Preferred provider organization (PPO) | An insurance plan in which patients choose a provider form a specific list, resulting in reduced costs for medical insurance. |
| Prime vender | A large distributor of medications and retail products that contracts with the pharmacy to deliver the bulk of their medications in exchange for lower prices. |
| Prior Authorization | Insurance-required approval for restricted, nonformulary or noncovered medication before a prescription medication can be filled |
| Safety data sheet (SDS) | Information sheets supplied to the pharmacy from the manufacturer of chemical products, the SDS list the hazards of the product and procedures to follow if a person is exposed to that product |
| Trade, Brand, or Propriety drug name | The name a company assigns for marketing and identification purposes to a commercial drug product. most brand names are trademarked and belong to the originator products named products are often protected for a time by patients |
| Treatment authorization request (TAR) | The process used by Medicare and medicated for authorization of assertive technology devices consisting of more than $100; durable medical equipment also requires a TAR similar to a preauthorized form |
| TRICARE (formerly CHAMPUS) | A health benefit program for active duty and retired personal in all seven uniformed services, it also covers dependents of military pesroneal who were killed while on active duty. |
| Wholesalers | COmpanies that stock a variety of drug manufacturers medciations and normally have a "just in time |
| Worker's' compensation | Government-required and government-enforced medical coverage for workers injured on the job paid for by the employer, the programs managed by each state in accordance with the state's workers compensation laws |
| 1965 | Medicare and Medicaid were signed into law |
| 1966 | Nineteen million people requested Medicare benefits |
| 1972 | Medicare expanded coverage to include individuals younger then 65 with low income and those with end-stage renal failure |
| 1977 | Medicaid and Medicare were placed under the control of the social security administration |
| 1980 | Medigap was introduced to fill the gap in Medicare coverage; patients could choose among 12 different medigap groups |
| 1986 | Medicaid expanded coverage to include infants and pregnant woman with low income |
| 1987 | Medicare and Medicaid payment was linked to the Omnibus Budget Reconciliation act of 1987(OBRA87) and specifically addressed poor conditions in nursing homes |
| 1988 | Medicare introduced a prescription drug benefit plan |
| 1990 | OBRA 90 required all health care personal; participating in Medicare and Medicaid program protect patient privacy it also required patient consolation with pharmacist |
| 1996 | The Health Insurance Portability and Accountability Act (HIPPA) implemented patient privacy rules for Medicare payment and provided electronic payment method |
| 1997 | Medicare made several important changes that expended coverage and developed 5 new payment systems |
| 1997 | Both Medicare and Medicaid were placed under the control of the health care financing administration |
| 2003 | The Medicare Modernization act (MMA) provided drug discount cards to eligible individuals |
| 2004 | A temporary Medicare-approved drug discount card program began, along with transitional assistance program to provide $600 annual credit to low-income Medicare beneficiaries without prescription drug coverage |
| 2005 | Medicare began covering a "welcome to Medicare' physical along with other preventive services |
| 2006 | Medicare part D was enacted, requiring the federal government to provide subsidies to participants within income below the federal poverty limit |
| 2010 | Medicare spending was reduced; Medicaid enrollment and spending were increased and new payments and reimbursement guidelines for Medicare and Medicaid services were introduced. |
| 2011 | Medicare began covering preventable services such as mammograms and colonoscopies without charging part b coinsurance or deductibles |
| 2011 | Federal payments were prohibited to states for Medicaid services related to certain health care-acquired conditions |
| 2012 | States received 2 more years of funding for children's health insurance program (CHIP) to continue coverage for children not eligible for Medicaid |
| 2013 | The patient Protection and Affordable Care act (ACA) requires a increases of Medicaid payments for primary care physicians' services. |
| 2014 | Affordable insurance exchanges were created and implemented. individuals with a small business can sign up and buy affordable health care benefits. The new system will determine eligibility and coordinate enrollment for Medicaid and the CHP |
| 2015 | Federal matching funds for CHIP will increase by 23% points with a cap of 100% to help states pay for coverage of uninsurance children |
| 2020 | Part d donut hole is closed and newly eligible Medicare members are no longer eligible for Medigap C or plan F because of covid 19, vaccines and testing are covered in part D members |
| Medicare part a | Hospital insurance. |
| Medicare part b | Physicians' services |
| Medicare part c | Allows patients in Medicare parts A and b to obtain additional insurance through private HMO or PPO |
| Medicare part d | Provides people who are eligible for Medicare a voluntary prescription drug plan |
| Class 1 recall | recalls for drugs that may pose a serious threat to users |
| Class 2 recall | Recalls for drugs that may cause temporary health problems and have a low risk for creating a serious problem |
| Class 3 recall | Recalls for drugs that violate FDA regulations concerning container defects or have a storage taste or color |
| Yellow waste container | Chemotherapy waste |
| Black waste container | drugs such as Nitroglycerin must be put in this bin, along with neostigmine, warfarin and phentermine |
| Purple waste container | live vaccines or hazardous waste |
| Blue an White waste container | non hazardous waste |
| DAW 0 | No Product Selection Indicated (may also have missing values) |
| DAW 1 | Substitution Not Allowed by Prescriber |
| DAW 2 | Substitution Allowed - Patient Requested That Brand Product Be Dispensed |
| Health Maintenance Organization (HMO) | An insurance plan allows coverage for in-network only physicians and services and uses the primary care physician (or provider) as a "gatekeeper" for the patients health care, patients often have copays to defray the cost of medical care |
| DAW 3 | substitution Allowed - Pharmacist Selected Product Dispensed |
| DAW 4 | Substitution Allowed - Generic Drug Not in Stock |
| DAW 5 | Substitution Allowed - Brand Drug Dispensed as Generic |
| DAW 6 | Override |
| DAW 7 | Substitution Not Allowed - Brand Drug Mandated by Law |
| DAW 8 | Substitution Allowed - Generic Drug Not Available in Marketplace |
| DAW 9 | Other |
| Clinical trials phase 1 | 20-80 The typical number of healthy volumeters used in phase 1, phase 1 emphasizes safety |
| Clinical trials phase 2 | 100's the typical number of patients used in phase 2, in this phase emphasizes effectiveness |
| Clinical trial phase 3 | 1000's the typical number used in phase 3 these study's gather more information about safety and effectiveness |
| Clinical trial phase 4 | post marketing because it's not possible to predict all of the drug's effects during clinical trials, monitoring safety issue after drugs get on the market is critical. |
| Stages of drug Development and review 1 | Animal testing discovery and Development |
| Stages of drug Development and review 2 | IND Application Preclinical Research |
| Stages of drug Development and review 3 | Phase 1 testing Clinical Research |
| Stages of drug Development and review 4 | Phase 2 testing FDA Drug Review |
| Stages of drug Development and review 5 | Phase 3 testing FDA Post-Market Drug Safety Monitoring |
| Stages of drug Development and review 6 | Review meaning |
| Stages of drug Development and review 7 | NDA Application |
| Stages of drug Development and review 8-9 | application reviewed |
| Third party billing | involves outsourcing billing tasks to external entities. This strategic measure allows healthcare providers to prioritize patient care while experts manage billing processes. It’s a cornerstone of healthcare finance solutions, optimizing revenue collecti |
| Drug Topics Red Book | access to current and accurate drug pricing and description information. Description RED BOOK covers FDA-approved drug products. It includes prescription drugs, over-the-counter drugs, and nondrug products. |
| limitation of plan exceeded | When you surpass your plan limit, you will need to cover the remainder of your medical costs for the rest of your cover period. Remember If you surpass your plan limit two months before the end of your plan, you couldn't renew and use next year's plan li |
| fast mover | are medications filled or sold several times each day in the pharmacy |
| slow mover | slow and non-moving pharmaceuticals are drugs with stocks more than the maximum level and the average usage. |
| special orders | Drugs are typically used by only a few patients, but they may be important for proper treatment |
Created by:
Ashley Ridgeway