A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Acute Care Additional Copay Administrative Services Agreement Adjudication Average Wholesale Price or "AWP" Benefits Package Brand Drug Calendar Year Claim COB Coordination of benefits COBRA Copay Covered Expenses Covered Person DAW Deductible Dependent Dispensing Fee Dose Optimization Program DMR Drug Formulary DUR Edit Effective Date Eligibility Employee Employer ERISA FDA Generic Drug Group HMO Initial Eligibility Date Maximum Allowable Benefit MAC Mail Order Pharmacy Maintenance Drug Non-Participating Pharmacy Non-Preferred Out of Pocket OTC PA Participant Participating Pharmacy Pharmacy Pharmacy Network Plan Limitations POS edits PPO Preferred Prescription Drug Restriction Step Therapy Utilization Review
Medical or pharmacological treatment for
episodic or short-term illness.
An additional copay is charged once a member
uses his/her maximum allowable benefit. The member is responsible for
any fees that exceed the amount allowed by his/her health plan. Additional
co pays are sometimes referred to as "out-of-pocket" expenses.
The Administrative Services Agreement entered
into between the client and Avia Partners.
Processing a pharmacy claim.
The average wholesale price (AWP) is the
cost of pharmaceuticals determined by the industry's Blue Book unit
price.
The combination of various drugs and therapies
which a medical provider covers for its members. Examples may include
the substitution of higher cost brand-name drugs for equally effective
generic equivalents.
A drug that is protected by a patent and
marketed under a trade name (whether or not such name is registered
or trademarked).
The period covering January 1 through December
31 of any given year. This term is usually used to calculate deductibles
paid by a member.
An itemized statement from the pharmacy that
includes the drug provided and its cost.
(COB) refers to instances where a member
is entitled to benefits from more than one plan or carrier. The most
common COB codes used to adjudicate claims are:
•
primary
coverage
•
secondary
coverage
The Consolidated Omnibus Budget Reconciliation
Act (Pub.L. 99-272), A federal law which requires most employers sponsoring
group health plans offer employees and their families the opportunity
for a temporary extension of heatlh coverage at group rates in certain
instances where coverage under the plan would otherwise end.
The "out of pocket cost" paid by the member
that helps defer the cost of prescription drugs. If a copayment applies
to a member, he/she will pay a percentage of the drug cost to the pharmacist.
The copay amount is determined by the member's health plan and is administered
at the benefit level.
The costs incurred with respect to prescription
services for which benefits are provided.
Any Participant or Dependent while such Participant
or Dependent is covered under the client's health plan.
A dispense as written (DAW) designation instructs the pharmacist on how a prescription can be filled.
A clause in a prescription benefit for which
the member is responsible. This means that the member must pay the deductible
amount set up by the health plan prior to when his/her true copay benefit
starts.
A person who is designated as such in the
client's health plan. Dependents are covered under the employees benefit.
A fill fee is an amount which is determined by the health plan that is paid to the pharmacy in addition to the calculated price of the drug. Also known as dispensing fee.
Dose optimization or dose consolidation for selected medications. The purpose is to change multiple dose medications to a single daily dose where appropriate.
A direct member reimbursement (DMR) is processed when a member pays out-of-pocket for a prescription and submits the receipt and claim form for reimbursement.
A list of preferred drugs or products that are covered by the health plan. Formularies can be: open-there is little or no limitations to the drugs covered; closed-drugs are limited to what is contained in the formulary; or custom-a formulary which allows for some flexibility in drug choice.
Drug utilization review (DUR) is a process which evaluates particular drugs for use by a specific member. This process is conducted using specific edits-designed by the health plan and Avia Partners which are programmed into our claims processing computer. Examples of DUR edits include: pregnancy, therapeutic duplication, age precautions, dose range, drug interaction precautions, and gender compliance.
An edit is used to alter the way a certain drug product is dispensed or processed. Edits include: point-of-sale restrictions (or DUR), benefit design edits (pricing and copay structure to be applied), restriction edits (not in formulary), or carrier edits (does claim fall into the required time and date parameters?).
The first date a plan, such as a prescription benefit plan, begins processing claims for the Plan Sponsor.
Eligibility defines the specific requirements which members of a health plan must satisfy in order to be insured. Eligibility is also used to determine the drugs and therapies that are covered by the plan. For example, a plan may cover certain brand-name blood pressure medications, while others may require that special criteria-such as a prior authorization-are met in order to be eligible.
Any individual in the employ or formerly in the employ of the Employer at a specific date and time.
The entity to which an employee is employed.
The Employee Retirement Income Security Act of 1974 which regulates employee retirement and welfare plans.
The U.S. Food and Drug Administration (FDA) is the public health agency responsible for protecting American consumers by enforcing the federal food, drug, and cosmetic act, as well as several other related health laws.
A drug which is manufactured by a company that is not the innovator. Generic drugs are chemically equivalent, and have been approved by the FDA. Most generic drug names reflect the chemical name of the drug. These drugs are less expensive-yet have the same therapeutic value-so their use is widespread.
A group is a subdivision within a main organization which separates members who have different eligibility benefits. Each group of members is divided by a unique code, and may be further subdivided.
A health maintenance organization (HMO) is a corporation that provides comprehensive maintenance and acute medical care to patients. HMOs usually prescribe their own eligibility limits to their members which coincide with the level of insurance held by the patient. HMOs provide preventive medicine, while employing primary care physicians as referrals for more substantial treatment.
The first day on which an Employee may become a Participant in the Employer Health Plan.
The maximum allowable (dollar) benefit (MAB) is an amount set by the health plan limiting the prescription benefits available to a member or family. Once the maximum is met, members are usually required to pay cash for future prescriptions.
A maximum allowable cost (MAC) is applied to a multi-source drug to encourage generic utilization and offer an alternative to AWP pricing, resulting in cost savings for the health plan.
Mail order pharmacies are used by many plans as a cost saving and convenient alternative to retail pharmacies. Members typically order their drugs via fax, telephone, email, or the Internet. Prescriptions can be paid with a personal check or accepted credit cards. Once a prescription order is received by the mail order pharmacy, members usually receive their prescription within 7 days.
A drug is considered a maintenance medication when it is being taken to treat chronic condition for an extended amount of time. Some drug programs allow maintenance medications to be dispensed in quantities that exceed a 34-day supply.
A Pharmacy that is not a participating Pharmacy per the client's request or because there is no contract in place.
A non-preferred drug is an alternative that may be prescribed instead of a preferred drug. Usually, non-preferred drugs are associated with higher copay amounts. These drugs are often restricted-requiring a prior authorization (PA)-or excluded from the formulary completely.
Out-of-pocket (OOP) refers to a member's cash expenses.
An over-the-counter (OTC) drug is a drug or product that is sold directly to the general public and does not need a prescription. An example of an OTC drug is aspirin.
Prior authorizations (PAs) are necessary to override claims that would otherwise be denied. Guidelines are established by the health plan which determine the criteria that must be met before a "prior authorization required" claim will be processed.
An Employee who has attained the Initial Eligibility Date and who is enrolled in the Employer Health Plan.
A properly licensed Pharmacy that has entered into a Pharmacy Services Agreement with Avia Partners, pursuant to which the Pharmacy agrees to provide pharmacy services to Participants and Dependents at a price agreed-upon in advance by the Pharmacy and Avia Partners.
A place where drugs and medicines are dispensed.
The group of pharmacies with which Avia Partners has contracted to receive discounted prices.
Some drugs are subject to quantity limits (QL) on the amount of the medication that a plan participant can receive (number of day' supply, quantity limits, frequency of fills, etc).
Edits set up by the plan that are processed when the claim is submitted electronically by a pharmacy. Some point-of-sale (POS) edits give pharmacists dispensing restrictions or instructions, as well as alternative therapeutic substituting messages such as "Use generic" or "Substitute with_____."
A Plan Physician Only (PPO) designation limits members to a specific panel of physicians.
The health plan-in an attempt to encourage the use of a particular manufacturer's product-may lower a copay applied to a member or raise the pharmacy's fill fee for that product as an incentive.
A drug that has been approved by the FDA, and under federal or state law, is prohibited to be dispensed without a prescription written by a licensed physician.
A limitation on a particular drug or group of drugs. Examples of restriction edits are: PA required, member age restriction, not in formulary, or quantity limits.
A number of specific drug classifications designated to be prescribed in a progression. Selected drug classes are reviewed and based on medical evidence and cost. Physicians must verify the patient's failure with a step drug progression or provide medical documentation that the patient should be dispensed a drug our of sequence.
Process in which Avia Partners reviews patterns of drug usage including distribution across employees and types of drugs.