PLEASE CHOOSE A LETTER:
Mail Order:Usually utilized for processing prescriptions for maintenance medications. Most plan designs allow 90 day provide of medication which contrasts with the 30 day supply normally dispensed by a retail pharmacy. Additional cost savings may be appreciated due to reduced copay being assessed for mail order prescriptions. For example the client may pay an amount identical to one or two copays, rather than the three copays associated with having three prescription refills from a retail pharmacy.
Maintenance Medications:Prescriptions that are applied on a continuous basis for long term medical conditions or diseases. For example: high blood pressure.
Maximum Allowable Cost (MAC):Managed to determine the payment schedules for generic drugs. Symbolizes the maximum amount the PBM or carrier will compensate a pharmacy for dispensing the generic version of precise drugs on the list.
Non-Preferred:Drugs excluded from the Preferred Drug List or formulary. Depending upon the profit plan design, non-preferred drugs may not be enclosed at all, or may have higher copays or coinsurance amounts.
Open Formulary:The benefit plan includes drugs which are listed on the formulary and those that are not listed. However, the plan is regularly ordered to incent the member to use formulary medications as non-formulary drugs will be subject to higher coinsurance or copayments. The primary reason of the formulary is to support use of listed medications.
Over-the-Counter (OTC):As the name involves, these medications are sold over the counter. No prescription is required in order to buy these products. (Examples: ibuprofen or Claritin). In most cases, OTC drugs are not enclosed under pharmacy benefit designs.
Patient Profiling:A review of prescription claims on a customer basis to recognize any patterns or trends, as well as potential concerns or occasions for customer education.
Pharmacy and Therapeutics Committee:A group of specialists consisting of physicians, pharmacists and clinical experts who help PBM's in developing formularies and preferred drug lists which are clinically suitable.
Pharmacy Benefit Manager (PBM):A salesperson who offers a set of core services to a customer (such as an insurance carrier or employer) to control drug expenditures.
Physician "Detailing":Direct physician contacts by pharmaceutical manufacturers to instruct providers about their products in plans of influencing the physician's prescribing patterns.
Physician Profiling:A re-evaluate of prescriptions written by physicians in a community or region to recognize any providers whose prescribing practices are outside of the usual range. For example, are there physicians who appear to contain a tendency to prescribe brand name drugs constantly when a generic equivalent exists?
Preferred Drug List:This term is habitually used interchangeably with formulary. A list of brand name and generic drugs which the carrier encourages members to use.
Prior Authorization:A requirement to get approval prior to a drug distributed by a pharmacy. The intention of this rule is to guarantee the appropriateness and suitability of the medication for the client, and as a cost containment measure.