Basics
A drug approved by the FDA that is therapeutically equivalent to a brand-name product
What is a Generic Drug?
A list of covered medications maintained by a health plan
What is a formulary?
Members must use pharmacies within the contracted network for coverage. What type of contract is this?
These organizations administer prescription drug benefits for health plans and employers
What are Pharmacy Benefit Managers (PBMs)?
This part of Medicare covers prescription drugs
What is Medicare Part D?
A fixed dollar amount a patient pays for a medication after insurance
What is Copayment?
This utilization management strategy requires approval before a drug is covered
What is prior authorization?
Where did our Chapter's President (Rabia) go for undergrad?
What is UMD?
This entity evaluates the clinical and economic value of medications for formulary decisions
What is a Pharmacy & Therapeutics (P&T) Committee?
This joint federal and state program provides coverage for low-income individuals
What is Medicaid?
Application of clinical and scientific evidence to support the appropriate use of medications to enhance patient and population health outcomes while optimizing the use of limited health care resources.
What is Managed Care Pharmacy?
This policy requires trying a preferred drug before a non-preferred one is covered
What is step-therapy?
What gift cards have we had at the seminar events previously? Name 2/3
Crumbl, CFA, Starbucks
A pharmacist-provided service designed to optimize medication use and improve outcomes, available for Medicare Part D beneficiaries with multiple chronic conditions and high drug costs
What is Medication Therapy Management (MTM)?
This federal program provides healthcare coverage for people 65 and older?
What is Medicare?
Manufacturer’s list price for a prescription drug for sale to wholesalers or other direct purchasers, before any discounts, rebates, or other price concessions.
What is WAC (Wholesale Acquisition Cost)?
These payments from manufacturers to PBMs are used to secure formulary placement
What are rebates?
Where will AMCP Nexus be in 2026?
What is San Diego, CA?
This type of health plan requires members to choose in-network primary care providers and obtain referrals for specialist care
What is a Health Maintenance Organization (HMO)?
These Medicare plans are offered by private insurers and combine hospital, medical, and often prescription drug coverage into one plan
What is Medicare Part C?
Explain the difference between comparative effectiveness and clinical efficacy
Accepting multiple responses
The formal process used to request reconsideration of a denied prior authorization coverage decision
What is Appeals Process?
What was the name of the condition or drug that we discussed on the last seminar series case?
What is Hereditary Angioedema? What is donidalorsen?
A performance-based contract among payer, provider, and/or manufacturer stakeholders in which reimbursement is tied to patient health measures or other real-world outcomes and costs for a defined period of time.
This program helps reduce prescription drug costs for Medicare beneficiaries with limited income by lowering premiums, deductibles, and copays
What is the Extra Help (Low-Income Subsidy) program?