Pay it or Plan It
Formularies within our database.
What is health plan?
The formulary benefit design determines the coverage of drugs and the co-pay assignment.
What is Tier?
The entity that controls the claims adjudication process for a payer.
What is Claims Processing?
This restriction typically limits the quantity of drug that will be covered.
What is Quantity Limit?
Healthcare and Prescription programs/coverage offered to employees, spouses and retirees of certain Federal Agencies and Organizations.
What is FEHBP?
Managed care organizations responsible for the member benefits.
What are Payers?
This benefit design is most common in the commercial space; most often it has a 3 or 4 tier structure.
What is standard benefit design?
This header is used to indicate if a PBM is involved in the formulary process.
What is Formulary Influencer?
This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
What is Prior Authorization?
Average Copay is a weighted average based on this.
What is based on the number of lives for a particular plan/payer?
The business entity that owns the provider organization.
What is parent?
Drugs at this level are frequently considered to have a lowest branded co-pay (LBC).
What is Tier 2 Standard?
For each payer/employer in the system, we collect information on the following aspects of control.
What is Formulary Management, Specialty Pharmacy Mail, Order Provision, Retail Management and Claims Processing?
This restriction typically requires that certain criteria be met prior to approval for the prescription.
What is Step Therapy?
Includes traditional Medicare Part A (hospital coverage).
What is Medicare Advantage, or Medicare Part C?
This entity controls and has the greatest sphere of influence over various pharmacy distribution functions for a payer.
What is PBM?
Most commonly, these are specialty products.
What is Tier 4 - Standard?
There is often a cost-savings associated with use of these entities, where a member can obtain a 3-month supply for the cost of 2 x month co-pays.
What is Mail Order Provider?
Custom groupings created for a nomenclature set.
What are Detailed Restrictions?
Used to further define the level of PBM involvement at a payer/employer.
What is Custom or Template?
These allow active employees or retirees to purchase health insurance using funds contributed by their employer.
What is Private HIX?
Non-formulary drug in a managed Medicaid plan.
What is NC/PA?
Traditionally been used to define a payer-controlled Pharmacy Committee.
What is In House?
Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
What is other restrictions?
43C
What is plan exclusion reason code?