Health Care Matters
A participant in a health plan; a person covered by health insurance.
What is a Member?
A cost-sharing arrangement in which a health plan member pays a specified charge for a specified service, such as a fixed dollar amount for a prescription drug.
What is a Copay?
This is the preferred method to measure medication adherence.
What is PDC (Proportion of Days Covered)?
Intentional misuse of information in order to persuade another to part with something of value or to surrender a legal right. It could also be an act of planned deception or misrepresentation. It always involves intent and some violation of trust.
What is Fraud?
Discount cards provided by pharmaceutical manufacturers to patients to reduce patient cost share for prescriptions for a certain period of time.
What are Copay Cards?
These are specialty drugs that are only available in certain specialty pharmacies. They are usually expensive and require special handling, monitoring, or administration.
What are Limited Distribution Drugs?
A group of physicians, health care professionals, hospitals, or pharmacies that a managed care organization has contracted with to deliver services to its members.
What is a Network?
These are pharmacy programs developed by health plans which enhance patient and population outcomes.
What are Clinical Programs?
A continually updated list of medications, products and technologies supported by current evidence-based medicine.
What is a Formulary?
An organization that represents health insurers, self-insured employers, union health plans, and government purchasers in the selection, purchase, and distribution of pharmaceuticals; a broker of purchases between payers on behalf of patients, drug manufacturers, and pharmacies.
What is a PBM (Pharmacy Benefit Manager)?
A structured approach to financing and delivering covered health care benefits that optimizes cost, utilization, and quality.
What is Managed Care?
A cost-sharing arrangement in which a health plan member pays a percentage of the charge for a specific service.
What is Coinsurance?
These measures are maintained by the National Committee for Quality Assurance (NCQA) and cover a wide range of healthcare services.
What are HEDIS Measures?
To use, consume, spend or expend thoughtlessly or carelessly; it may or may not provide the person with personal gain.
What is Waste?
A manufacturer price concession that occurs after drugs are purchased and involves the manufacturer returning some of the purchase price to an organization providing pharmacy benefits that is set in contractional terms; may be based on volume, market share, outcomes, or other factors.
What is a Rebate?
The companies perform research, develop and bring new drug products to market; they establish list price.
What are Manufacturers?
This is a group of physicians, pharmacists, and other relevant experts in the diagnosis and treatment of disease and preservation of health who determine drug coverage at a health plan.
What is a P&T (Pharmacy and Therapeutics) Committee?
Admisters a pharmacy benefit program processing electronic prescription drug claims, negotiating financial contracts with pharmacies and drug manufacturers, provides customer service support to members, develops and mains a drug formulary, ensures compliance with applicable government regulations, and provides clinical and quality programs.
What is a PBM (Pharmacy Benefit Manager)?
Any number of measures used to ensure appropriate medication use such as quantity limits, prior authorization, or step therapy.
What is Utilization Management?
Non-specialty medications are likely to be billed on this benefit if they are not administered by a healthcare provider.
What is the Pharmacy Benefit?
This legislation provided federal funding for managed care organizations.
What is the Health Maintenance Organization Act of 1973?
The portion of payment for covered health services required to be paid by the health plan member including copays, coinsurance and deductibles.
What is Out-Of-Pocket Cost?
This rating system is used by CMS to measure the quality of Medicare plans. The ratings help consumers compare health plans.
What is the Star Rating System?
Providing information or documentation for a health care claim in a manner that improperly uses program resources for personal gain or benefit, yet without sufficient evidence to prove criminal intent; it is very close to fraud, but is often not prosecutable as such.
What is Abuse?
Contracted rate of compensation paid to a pharmacy for filling a presecription and processing the claim; added to the negotiated formal method for reimbursing ingredient cost.
What is a Dispensing Fee?
A drug that has a trade name and is protected by a patent; may be produced and sold by the company holding the patent.
What is a Brand Name Drug?
This private, not-for-profit organization works to improve healthcare quality through the administration of evidence-based standards, measures, programs, and accreditation.
What is NCQA (National Committee for Quality Assurance)?
This framework calls on organizations and communities to accept responsibility to improve patient experience, improve the health of populations, and reduce the per capita cost of health care.
What is the Triple Aim Framework?
A type of utilization management that requires health plan approval for members taking certain drugs for a claim to be covered under the terms of the medical or pharmacy benefits; promotes the use of medications that are safe, effective, and provide the greatest value.
What is a PA (Prior Authorization)?
This is the benefit consisting of medications that a patient cannot typically take themselves without assistance of a health care professional.
What is the Medical Benefit?
This is the percentage of Americans who have prescription drug coverage.
What is 85%?
Time off from work is an example of this type of healthcare cost.
What is an Indirect Cost?
Comparison of quality measure results to an external standard or predetermined performance threshold.
What is a Benchmark?
A process used by a member to request coverage for an insurance claim that the insurer has denied.
What is the Appeal Process?
This is the list for generic drug reimbursement.
What is a MAC list?
A structured, ongoing review of prescription drug use against predetermined standards; occurs prospectively or retrospectively and includes educational programs to educate prescribers on common drug therapy problems.
What is a Drug Utilization Review?
A national quality organization dedicated to improving medication safety, adherence, and appropriate use; a measure developer.
What is PQA (Pharmacy Quality Alliance)?
A real-time consultation about a member's medications conducted by a pharmacist or other qualified health care professional via telehealth or telephone or in person.
What is a CMR (Comprehensive Medication Review)?
A type of utilization management that limits the amount of medication dispensed per fill to reduce waste and overuse.
What is a Quantity Limit?
A pharmacist-conducted review of all medications to help individual patients get the most benefit from their medication and detect and prevent medication problems
What is MTM (Medication Therapy Management)?
An organization that offers benefit products, which may include, medical, pharmacy, dental, vision, and/or chiropractic benefits to private and public purchasers.
What is a Health Plan or Managed Care Organization?
This type of healthcare cost cannot be quantified or measured in monetary terms.
What is Intangible Cost?
This type of insurance requires that targeted members have a CMR at least once every 365 days.
What is Medicare?
Examples are lack of safe housing, transportation, and healthy food, and they can have a major negative impact on members' health and well-being.
What are Social Determinants of Health?
This is the ‘list price’ of a prescription drug.
What is WAC (Wholesale Acquisition Cost)?
These types of drugs are hard to define. They are usually expensive, and treat complex conditions like cancer, multiple sclerosis, and rheumatoid arthritis.
What are Specialty Drugs?
A group of doctors, hospitals, and other health care providers who work together to provide coordinated high-quality care to their Medicare patients and accept financial risk/reward tied to clinical outcomes.
What is an ACO (Accountable Care Organization)?
This type of health plan is delivered by the each state and is usually capitated managed care.
What is Medicaid?
A type of utilization management that requires the use of a safe, lower-cost drug first before a second drug that is usually more expensive is approved under the terms of the medical or pharmacy benefit.
What is Step Therapy?
This type of health plan is sometimes referred to as "Obamacare".
What is Marketplace?