key terms
A challenge on a reimbursement form a PBM or insurance provider on a prescription claim that has been previously processed
Audit
The amount that the patient is to pay for each prescription as determined by the insurance carrier
Copayment (copay)
The accumulation of all sales receipts before deducting expenses
Gross Profit
The difference between the acquisition cost and the selling price; also called gross profit
mark up
A record that accounts for each unit of Schedule 2 drug dispensed or recieved
perpetual inventory
record
The average price that wholesalers charge the pharmacy for a drug, serving as the benchmark price to estimate reimbursement rates and retail price without insurance
AWP (Average Wholesale
Price)
An amount on some insurance plans that must be paid by the insured person before the insurance company considered paying its portion of a medical or drug cost
Deductible
The entire stock of products on hand for sale at a given time
Inventory
A state governmental health insurance program for low income and disabled citizens
Medicaid
PBM" stands for "Pharmacy Benefit Manager," which refers to a company that acts as an intermediary between health insurance companies, pharmacies, and drug manufacturers, managing prescription drug benefits by negotiating prices, creating formularies (lists of covered drugs), and processing claims for patients
PBM
A rejection of a prior prescription claim by a PBM or an insurance provider that must be investigated and resolved
chargeback
a temporary limit on what Medicare Part D prescription drug plans will cover for drugs
Donut Hole
The amount of time the average drug inventor will be replaced during a 12-month period; most pharmacies replace inventory every two to four weeks
Inventory Turnover rate
A federal and state partnered insurance program that provides partial coverage of prescriptions, primarily for patients who are eligible for medicare
Medicare—Part D Pre-
scription Drug Coverage
The Process of reconciling an invoice and updating inventory at time of receipt of stock delivery
Posting
A percentage based insurance plan in which the patient must pay a certain percentage of the prescription price; commonly used in high cost specialty drugs
Coinsurance
Insurance coverage in which a patient paus one copay for brand name drugs and a lower copay for generic drugs; also known as two-tier
Dual copay
The total value of the entire stock of products on hand for sale on a given day
Inventory Value
disposable or have a short useful life, and are primarily used for a medical purpose
Nondurable medical sup-
plies
a list of prescription drugs that are preferred by a health insurance plan or employer. PDLs are also known as formularies
Preferred drug list
Online billing of both a primary and a secondary insurer
COB
Medically necessary, reusable equipment such as nebulizers, hospital beds, wheelchairs, and walkers that may be purchased in a community pharmacy or billed to Medicare Part B
DME
Frequent Purchasing in quantities that just meet supply needs until the next ordering time
JIT purchasing
Realtime insurance claims processing iva electronic wireless telecommunications
online adjudication
A approval for coverage of a high cost medication or a medication not on the insurers approved formulary obtained after a prescriber calls the insurer to justify the use of the drug
PA