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Pharmacy Terms

Across
not a separate benefit, but rather the part of Medicare policy that allows private health insurance companies to provide Medicare benefits.
Average Wholesale Price; it is used by pharmacy benefit managers and health insurance companies to calculate drug product reimbursement rates.
Numeric system to identify drug products in the United States. A drug’s NDC number is often expressed using eleven digits in a 5-4-2 format (xxxxx-yyyy-zz) where the first five digits identify the manufacturer, the second four digits identify the product and strength, and the last two digits identify the package size and type
Drug that, by law, can be obtained only by prescription and bears the label, “Caution: Federal law prohibits dispensing without a prescription” or “Rx Only.”
one large pharmacy that packages medications and delivers them to smaller pharmacies for distribution to patients.
a drug sold by a drug company under a specific name or trademark that is protected by a patent and is typically more expensive than the generic version.
a specialty pharmacy dedicated to the compounding and dispensing of radioactive material for use in nuclear medicine procedures.
The process of evaluating prescribing patterns, and/or patient drug utilization against predetermined standards (e.g., treatment guidelines) to determine the appropriateness of drug therapy. Sometimes called drug use evaluation (DUE). There are three types: prospective (before pre-scription dispensing), concurrent (at point of dispensing), and retrospective (after a prescription is filled).
covers certain physicians’ services, outpatient care, medical supplies and preventive services.
A unique 10-digit identifier issued to healthcare providers by the Centers for Medicare and Medicaid Services for billing purposes.
A systematic approach to providing care to a population of patients with a specific disease. Patient and provider education, pharmaceutical care, continuous quality improvement, practice guidelines, patient monitoring, outcomes assessment, and case management may be included; however, program features vary widely.
The process of comparing a patient’s medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.
Terminology that is used to describe intentional misrepresentation, overutilization or in-appropriate utilization, and inconsistent practices with respect to recognized standards of care for healthcare services resulting in additional costs.
The study of how genes affect a person’s response to drugs. This field combines pharmacology (the science of drugs) and genomics (the study of genes and their functions) to develop effective, safe medications and doses that will be tailored to a person’s genetic makeup. Also known as “personalized medicine.”
United States law was designed to provide privacy standards to protect patients’ medical records and other health information provided to health plans, doctors, hospitals, and other healthcare providers.
a drug that has the same active-ingredient formula as a brand-name drug that usually costs less.
Standard medical codes used for medical, surgical, radiology, laboratory, and diagnostic procedures and services.
a fixed cost defined in the insurance policy that is paid by the insured person each time a medical service is rendered.
a group of pharmacies owned by a corporate entity all under the same name.
Amount that a member pays out of pocket before coverage begins.
Medical classification system which uses standard codes for diseases, signs and symptoms, and diagnoses.
the party to a medical benefits contract that may collect premiums, assume financial risk, pay claims and provide other administrative services.
a community (retail) pharmacy that is not directly affiliated with any chain of pharmacies and is not owned by a publicly-traded company.
Down
U.S. government program financed by federal, state and local funds, which covers hospitalization and medical insurance for persons of all ages within certain income limits.
The patient’s conformance with the healthcare provider’s recommendation with respect to timing, dosage, and frequency of medication taken during the prescribed length of time.
the creation of a particular pharmaceutical product to fit the unique needs of the patient
The landmark health reform legislation passed by the 11th Congress and signed into law by President Barack Obama in March 2010. This legislation, also known as the Patient Protection and Affordable Care Act (PPACA) includes a long list of health-related provisions that began taking place in 2010.
an insurance plan that only allows patients to visit specific providers to receive coverage for medications.
Any equipment used to provide therapeutic benefits to a patient due to a specific medical condition(s). This equipment may include wheelchairs, crutches, walkers, monitors, etc..,
tax-advantaged savings account for medical expenses for patients enrolled in health insurance with a high deductible.
Electronic process of evaluating prescription drug claims at the point of service to verify coverage and detect potential problems that should be ad-dressed before drugs are dispensed to patients.
Strategies required to be implemented by drug manufacturers to monitor and/or mitigate safety concerns. The U.S. Food and Drug Administration (FDA) can require manufacturers to establish these when known or potential safety concerns are present for a specific drug in order to ensure that the health benefits outweigh the risks
a service rendered by a pharmacist that provides a comprehensive and in-depth examination of a patient’s medication regimen that helps to ensure proper medication utilization.
provided only through private insurance companies with government contracts; mainly provides outpatient prescription drug coverage.
Centers for Medicare & Medicaid Services
a formal agreement in which a licensed provider makes a diagnosis, supervises patient care, and refers patients to a pharmacist under a protocol that allows the pharmacist to perform specific patient care functions (example: flu shots, dose alterations, etc.)
Products manufactured through biologic processes and similar to a reference biologic drug product.
A process under which a prescription claim is initially denied so that the health plan can evaluate the therapy before treatment starts. This process typically requires action from the physi-cian, pharmacist, or patient to obtain coverage.
the upper limit or maximum amount dictated by a payer or pharmacy benefit manager that they will pay for a certain medication.
Continuing education structure involving personal self-appraisal, educational plan development, plan implementation, documentation, and evaluation
an inspection of drug dispensing practices conducted over a specified time period. They can be conducted by someone internal or external to the organization.
pharmacy benefit manager; primarily responsible for processing and paying prescription drug claims, and are most often a third-party administrator