Prime Dictionary
B
Brand-name drug or brand prescription drug
A medicine that is manufactured and sold by a pharmaceutical company that holds a patent on the actual drug or the drug name. (For example: Lipitor® is a brand name for the cholesterol medicine atorvastatin calcium).
Brand/formulary drug
A brand-name drug that is on the covered drug list, (or formulary). Your share of the cost of these drugs will usually be higher than the cost of the generic equivalent.
Brand/non-formulary
A brand-name drug that is not on the drug list (or formulary). Your share of the cost on these medicines is typically higher than brand-name medicines that are on the drug list. Sometimes, these medicines are not covered at all.
C
Chain pharmacy
A group of pharmacies, usually three or more, that are owned or managed by the same company. Ex: Walgreens
Closed formulary
A type of benefit design in which only medicines included on the drug list (or formulary) are covered. You may be able to get a medicine that is not on the drug list. (See definition for Formulary Exception)
D
Date filled (fill date)
The date the prescription was filled, or service (for example, a flu shot), was provided.
Days supply
The number of days your prescription will last. This is sometimes based on how much of the medicine your doctor prescribes (for example, a 10-day supply). For medicine that you take every day (like blood pressure or cholesterol medicine), this generally is a 30 or 90-day supply.
Dispensing limitations
A plan may limit the number of days or the number of pills supplied for each prescription. A plan may also limit certain drugs based on the age of the member.
Dosage form
How the medicine is dispensed (tablet, capsule, liquid, cream, etc.).
Dose
A measured unit of your medicine that you would take at one time. For example: one pill every 8 hours, or 1 teaspoon one time per day.
Drug tier
Your plan's drug list will have different tiers, or levels of coverage, for medicines. The tier level typically determines your cost share, or amount you pay out of pocket.
E
Extended supply network (ESN)
Most retail pharmacies can only fill up to a 30-day supply of medicine. An extended supply network pharmacy can fill up to a 90-day supply of maintenance medications. These are usually medicines that you take every day to treat a chronic condition like high blood pressure or cholesterol, or for preventative purposes.
F
Food and Drug Administration (FDA)
The federal agency that monitors prescription drugs and reviews the drug manufacturers’ clinical testing to make sure that medicines are safe and effective. The FDA also keeps track of how drugs are manufactured and responds to reports of problems or risks.
Formulary
A list of medicines that your pharmacy plan covers depending on your benefit. The formulary is also referred to as the covered drug list. This list may change during the year, if new medications become available or if drugs are recalled.
Formulary exception
A type of coverage determination request. This request would be used to get coverage for a medicine not listed on the drug list (formulary), such as when your doctor believes a non-formulary drug is best for you, or to cover a drug without restrictions.
G
Generic drug
Generic drugs are chemically equal to the brand name drug, but don’t use the brand name. A generic drug is typically a lower-cost version of a brand-name drug, which becomes available when the patent expires on a brand-name drug. (For example: atorvastatin calcium is the generic name for the brand-name cholesterol drug Lipitor®.) Generic drugs are regulated by the Food and Drug Administration (FDA).
H
Home delivery pharmacy services (Mail Order Pharmacy)
A licensed pharmacy that fills your maintenance drugs and delivers them to your home. Home delivery pharmacy plans can save you time and money, and usually fill prescriptions for a three-month supply at a time.
Home Infusion Pharmacy
A pharmacy that focuses on home infusion therapy medicines and supplies.
I
In-network pharmacy
A pharmacy that is in the network; also called a network pharmacy.
Indian Health Services, Tribal and Urban Indian Health Program pharmacy
A pharmacy that serves the Indian Health Service, Tribal, and Urban Indian Health Program. Only Native Americans and Alaska Natives have access to these pharmacies through their Medicare Part D plan's pharmacy network.
L
Legend drug
A drug which cannot legally be obtained without a doctor's prescription. The original product container has the words: "Federal Law prohibits dispensing without a prescription." or "Rx Only."
Licensed prescriber
A doctor, nurse practitioner, physician's assistant or other individual who has been licensed by the state to prescribe medicine.
Long term care pharmacy
A pharmacy located in a long term care or nursing facility.
M
Mail-order pharmacy
A licensed pharmacy that fills your maintenance drugs and delivers them to your home. Also called home delivery pharmacy. Home delivery pharmacy plans can save you time and money, and usually fill prescriptions for a three-month supply at a time.
Maintenance drug
A prescription drug that treats a chronic condition (for example: diabetes, arthritis, high blood pressure, or heart disease).
Manufacturer
A company that makes and/or distributes medicines. A manufacturer can make prescription drugs or over-the counter products.
Maximum refills
The number of times you can refill a prescription without getting a new one from your doctor.
Medicaid
A state-run health plan for low-income and disabled people. The federal government and each state government share the costs of this program.
Medicare
A national health care plan that covers medical care and hospitalization, usually for people 65 and older. The Medicare health benefit has two main parts:
- Part A covers inpatient hospital costs.
- Part B covers doctor visits and outpatient costs.
- Medicare Part D is an extra service that people who are eligible for Medicare can buy from private insurers that covers prescription drugs
Medicare Part D
The official name of Medicare's prescription drug coverage.
Multi-source
Medicines that are made and sold by two or more manufacturers.
N
Non-formulary
A non-formulary medicine is not on your covered drug list. If you want to keep taking a non-formulary medicine, work with your prescriber to ask for a formulary exception or to switch to a different drug.
Non-preferred
A drug that may be covered by your pharmacy plan, but is not on the drug list (or formulary). You may be able to purchase a non-preferred drug, but it may cost you more than a preferred drug.
Non-preferred home delivery pharmacy
A licensed pharmacy that fills your maintenance drugs and delivers them to your home, but is not contracted with your pharmacy benefits manager. A non-preferred mail order pharmacy will have a higher copay/coinsurance than a preferred mail order pharmacy, which has an agreement with your health care plan.
Not covered
Prescription drugs that are not covered by your prescription drug plan.
O
Open formulary
A benefit design that covers all prescription drugs, not otherwise excluded under your plan, whether they are on the drug list (or formulary) or not.
Out-of-network pharmacy
A pharmacy that is not in the network of pharmacies.
Over-the-counter (OTC)
A medication that you can buy without a prescription from your doctor.
P
Paper claim
A request for payment for a covered product or service that you paid for when you received it. You submit the paper claim to your plan yourself.
Pharmaceutical equivalents
Medications that have identical amounts of the same active ingredients. They have the same dosage form (tablets, capsules, etc).
Pharmacy benefit manager (PBM)
A company that manages prescription drug benefits for a health plan or employer.
Pharmacy network
A group of pharmacies that have contracted with a health plan or pharmacy benefit manager to provide covered products and services to members.
Pharmacy types
A pharmacy is licensed to prepare, dispense and sell medicines. There are several types of pharmacies, including:
- Network pharmacy: A pharmacy that has a contract with a health plan or pharmacy benefit manager to provide covered products and services to members.
- Retail Pharmacy: A pharmacy located in a retail store instead of a hospital or clinic.
- Home Delivery/Mail Order Pharmacy: A licensed pharmacy that fills your maintenance drugs and delivers them to your home. Also called a home delivery pharmacy. Home delivery pharmacy plans can save you time and money, and usually fill prescriptions for a three-month supply at a time.
- Home Infusion Pharmacy: A pharmacy that focuses on home infusion therapy medicines and supplies.
- Long Term Care Pharmacy: A pharmacy located in a long term Care or nursing facility.
- I/T/U: An I/T/U pharmacy serves the Indian Health Service, Tribal, and Urban Indian Health Program.
Plan exclusion
Pharmacy benefit plans may not cover all prescription drugs, services or supplies. This is called a plan exclusion. You may also hear it called a benefit exclusion.
Plan paid amount
The amount that your plan pays to your doctor, pharmacy or you. You pay any remaining balance, which could include your copay, coinsurance, cost share or deductible.
Preferred drug
A drug that is included on your plan's drug list (also called a formulary). Benefit plans typically cover more of the cost of preferred drugs than they do of non-preferred drugs.
Preferred mail order pharmacy
A licensed pharmacy that fills your maintenance drugs and delivers them to your home. A preferred mail order pharmacy has a contract with your benefit plan, and will have a lower copay/coinsurance than a non-preferred mail order pharmacy.
Preferred pharmacy
If your health plan's pharmacy network includes "preferred pharmacies," you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred pharmacy. If your health plan's pharmacy network includes preferred pharmacies, you can filter by preferred pharmacies within the pharmacy search feature to compare cost estimates.
Prescribers
Health care professionals who are licensed by their state to prescribe medicines, for example: doctors, nurse practitioners, physician assistants and dentists.
Prescription drug benefit
Your prescription drug benefit is the method of reimbursing members or pharmacies for the cost of drugs, services or supplies.
Pre-authorization
Pre-authorization, that means that your plan must give authorization before it will cover certain medicines.
The list of drugs needing pre-authorization depends on your benefit plan.
Q
Quantity dispensed
The number of pills or amount of a medicine that was dispensed for a prescription. This number is shown in units like pills, capsules, ounces, cc’s).
Quantity limits
The maximum amount of a medicine that you can get for each fill. Quantity limits are based on the number of days or number of units (pills, capsules, ounces, etc.).
S
Specialty medicines
Specialty medicines treat chronic and complex conditions (for example, multiple sclerosis, cancer, hepatitis C and rheumatoid arthritis). Specialty medicines can be filled at a specialty pharmacy.
T
Therapeutic alternative
A medicine that treats a specific health condition as well as a more expensive brand-name drug. It could be a different brand-name drug that has been on the market for a longer time. Or it can be a generic medicine – a lower-cost version of a brand-name drug. Therapeutic alternatives work in a similar way, but have different ingredients.
Therapeutic classification
A system that places prescription medicines into categories, based on their active ingredients.
Therapeutic equivalent
A medicine that treats a specific health condition the same or as well as another drug. Both medicines have the same effects and safety standards.
Treatment category
A group of clinical conditions (for example, high blood pressure and high cholesterol) that health care professionals use to figure out how effective different treatments are.
TrOOP
"True out-of-pocket" costs that Medicare members pay for their prescriptions. This can include deductibles, coinsurance and/or copays.
U
Utilization Management
Some medicines on your drug list may have special requirements or rules. In the health care world, this is called utilization management. If you take a medicine with special requirements, work with your doctor to ask your plan for approval.
If you see a note next to a medicine on your drug list, here’s what you should know:
- PA or pre-authorization – a medicine needs to be pre-approved before it can be covered by your plan
- QL or quantity limits – you may only be able to receive a certain amount of your drug at one time
