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CMB-Chapter 9
CMB - Chapter 9 - Managed Care Rxs
| Question | Answer |
|---|---|
| PPO | Preferred provider organization |
| HMO | health maintenance organization |
| MCO | mananaged care organizations |
| PBM | pharmacy benefit manager |
| drug ingredient cost refers to .... | the price the pharmacy dept. pays for the medication |
| % of the drug product's published list price ia also known as... | average wholesale price (AWP) |
| MAC | maximum allowable cost |
| MAC is ... | an estimate of the cost of a generic equivalent and max amount the payer will pay for a certain drug product |
| patient cost sharing is... | designed to make patients more cost conscious & usually take the form of copayments, or deductibles & coinsurance |
| POS | point of sale |
| formularies are... | lists of meds that are covered or excluded from coverage |
| a daw provision... | allows pharmacies to be reimbursed for multiple-source brand-name drugs under some circumstances |
| DAW 0 = | no product selection indicated - product selection is not an issue - default |
| DAW 1 = | sub NOT allowed by prescriber - product is to be DAW |
| DAW 2 = | sub allowed, patient requested Brand product to be dispensed - generic sub is permitted |
| DAW 3 = | sub allowed, Rph selected Brand product to be dispensed - generic sub is permitted |
| DAW 4 = | sub allowed, generic drug not in stock |
| DAW 5 = | sub allowed, brand drug dispensed as generic |
| DAW 6 = | Override |
| DAW 7 = | sub not allowed, brand drug mandated by law |
| DAW 8 = | sub allowed, generic drug not avail. in marketplace |
| DAW 9 = | Other |
| DUR | drug utilization review |
| Most PBM's use DUR to | monitor patterns of prescribing, dispensing and usage of prescription drugs |
| Retrospective DUR | review of rx claims databases well after rxs have been dispensed |
| Prospective DUR | occurs before rx is dispensed |
| a rx that has been filled, billed & adjudicated needs to be reversed or "unbilled" when a patient does not receive the rx is called | claim reversal |
Created by:
cbowers101
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