Glossary of Prescription Terms
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The member's ability to obtain medical care. Access can be affected by availability of services, size of the network, location of the facilities, and affordability of coverage. Anthem’s prescription drug plan offers member access to prescription drugs through home delivery and a nationwide network of participating retail pharmacies.
Stands for: Angiotensin Converting Enzyme Inhibitors. The class of drugs that are used to treat cardiovascular conditions such as hypertension and heart failure.
Short-term (opposite of chronic)
Treatment for a short-term health problem, such as an illness or injury.
Determining the proper payment for an insurance claim. Through Anthem’s prescription drug plan, adjudication is part of the claims processing system and takes place at the time a prescription is dispensed.
Adverse Drug Reaction (ADR)
Occurs when a particular drug is harmful to a patient.
The therapeutic drug class that includes medications used to relieve pain.
Medications that are in the therapeutic drug class used to treat infectious diseases such as community-acquired pneumonia.
Medications that are used to treat cancer.
Approval of health care services. Anthem’s prescription drug plan uses pre-approved criteria, developed by Anthem’s Pharmacy and Therapeutics Committee and reviewed and adopted by your health plan, to provide authorizations for claims using real-time edits. For certain types of drugs, Prior Authorization is required.
The benefit level is the extent of service a health plan member is entitled to receive based on his or her contract with a health plan. Deciding benefit levels is part of the health plan's benefit design strategies
Brand name drugs
Prescription drugs that are manufactured and marketed under a registered trade name or trademark. If applicable, your drug list/formulary provides access to brand-name drugs as well as generic drugs.
Drugs in the therapeutic class of medications that are used to treat cardiovascular conditions such as heart failure, high blood pressure, etc.
The process in which a health care professional associated with the health plan supervises the administration of medical or ancillary services to a member. Case managers normally handle catastrophic disorders such as transplants or cancer. Disease State Management programs sometimes involve case management.
Central Nervous System (CNS) therapeutic class
The class of medications that are used to treat central nervous system conditions such as convulsions, depression, or Parkinson's Disease.
Certificate of Coverage
A document provided to a health plan member, as required by state law, which provides evidence that the member has coverage. It also gives basic information about the coverage.
Long-term, ongoing (opposite of "acute")
Long-term care for chronic illness.
Information submitted by a provider or covered person to establish that medical services were provided. The claim is used in processing the payment.
Licensed pharmacists who perform a variety of functions including continuously monitoring the pharmaceutical industry for new developments and trends, evaluating drugs before they are placed on our drug lists/formularies, serving as a clinical resource to network pharmacists, and working to improve prescribing practices through physician education.
Coinsurance limits the amount of a member's coverage under a health plan to a certain percentage, commonly 80 percent. The level of coinsurance is part of a plan's benefit design strategy.
Adhering to rules and guidelines that have been agreed to. Anthem’s prescription drug plan uses compliance in several contexts: For members, compliance generally means using drugs in compliance with written instructions. For physicians, Formulary Compliance means writing member's prescriptions for drugs on your drug list/formulary, if applicable. Pharmacy Audit Compliance means complying with guidelines for network contracts and following audit procedures.
Medications that the U.S. Food and Drug Administration has classified as potentially habit-forming or addicting. The FDA categorizes controlled substances as Schedule II, III, IV and V, based on their level of potential for physical and/or psychological addiction. Schedule V are the least addictive, and Schedule II are the most addictive, controlled substances.
Coordination of benefits (COB)
Coordination of benefits is a process used by health insurance companies to prevent double payment for services when a member has coverage from two or more sources. When a member has coverage through two separate insurers (their own and their spouses, for example) coordination of benefits is used to determine which insurance company has primary responsibility for payment.
A copayment (also called a copay) is the fixed amount of a medical expense or claim that a member must pay. Determining copayment levels that members will pay is part of a health plan's benefit design strategy. Copayments are required on the majority of prescription drug benefit plans.
Your prescription drug copayment will be the lesser of your scheduled copayment amount or the retail price charged for your prescription by the pharmacy that fills your prescription.
Strategies that aim to reduce health care costs and encourage cost-effective use of health care services. Our cost management strategies are designed to provide cost containment while maintaining a high standard of quality care.
Brand-name drugs which have the same chemical ingredients and are therapeutically equivalent, but are marketed under two or more different registered trade names or trademarks.
Dispense As Written (DAW)
DAW, written on a prescription by the physician, indicates that the physician wants the pharmacy to dispense the brand medication that is written on the prescription pad.
The portion of health care expenses that a member must pay out of pocket before any insurance coverage applies. Determining deductibles is one part of a health plan’s benefit design strategies.
An individual who receives health insurance through a spouse or parent.
Dermatological therapeutic class
The class of medications that are used to treat skin diseases.
Direct Member Reimbursement (DMR)
Direct member reimbursement is a paper claim submitted directly by a member. This method of reimbursement is used when a member has to pay full price for a drug or does not have their drug identification card with them at the pharmacy store.
A medical condition that presents a specific group of symptoms and clinical signs.
Disease State Management
The process of intensively managing a particular disease in all settings of care. Disease state management emphasizes prevention and health maintenance.
The day that health plan coverage, or a plan modification, goes into effect.
Various chemicals in the body that can carry electric charges. Electrolytes are present in the blood as acids, bases, and salts and can be measured by laboratory studies of the serum.
When an individual is eligible for coverage under a health plan.
Members enrolled in a benefit plan.
Endocrine therapeutic class
Medications that are used to treat diseases of the endocrine system such as diabetes or thyroid conditions.
The Anthem drug list/formulary is a list of prescription drugs that have been selected and approved by the Anthem Pharmacy and Therapeutics Committee for their safety, quality, and cost effectiveness. The Anthem drug list/formulary includes drugs from every therapeutic drug class, and also medical supplies, and medical devices. In addition, your health plan reviews and approves the recommendations of this committee. Medications are not evaluated based on cost* unless therapeutic equivalence has been established.
* Based on Average Wholesale Price (AWP)
Generic equivalents are medications that have active ingredients that are therapeutically equivalent to their brand-name counterparts. Generic equivalents become available when a brand-name drug patent expires. They may look different than their counterpart brand-name drugs in size, shape or color, but they meet the same U.S. Food and Drug Administration standards for safety, purity and potency.
The practice of dispensing a generic equivalent instead of the brand counterpart. Substitutions can only occur when a generic equivalent is available, when the substitution is allowed by law, and when the physician has not marked the prescription "dispense as written." Generic substitution may take place as part of several programs within Anthem’s prescription drug plan, including: real-time edits and Therapeutic Interchange.
Gastrointestinal therapeutic class
The category of medications that is used to treat gastrointestinal (GI) conditions.
The contract signed by a health plan and an employer group which constitutes their agreement regarding benefits and exclusions.
HMG-CoA therapeutic class
The class of drugs which includes medications used to treat elevated cholesterol levels.
Home Delivery Pharmacy
A home delivery pharmacy that serves members with a prescription drug benefit..
A drug that, by law, can only be obtained by prescription. Legend drugs are so named because the label bears this legend: "Caution: federal law prohibits dispensing without a prescription."
Mail service pharmacy
A pharmacy which is licensed to dispense and distribute pharmaceuticals via the U.S. Mail or other delivery services. See Home Delivery Pharmacy
Medication used to treat a chronic, or on-going, condition. May also be referred to as "continuous therapy medications."
A system of health care delivery whose goal is to give members access to quality, cost-effective health care while influencing utilization and cost of services, and measuring provider and plan performance.
Maximum Allowable Cost (MAC)
Maximum Allowable Cost (MAC) is the maximum reimbursement that Anthem’s prescription drug plan will pay to a pharmacy for each product on a specific list of generic medications. Maximum Allowable Cost is based on the acquisition cost of a drug, using a comparison of pricing from multiple sources. The MAC program is an important cost management strategy.
Maximum out-of-pocket cost
Maximum out-of-pocket cost is the most money a member will ever need to pay for covered services during a contract year. Once this limit is reached, the health plan pays for all services up to a maximum level of coverage. Maximum out-of-pocket cost normally applies in indemnity, PPO or POS plans.
An entitlement program run by both the state and federal governments that provides health care insurance to citizens younger than 65 years of age who cannot afford private health insurance.
An entitlement program run by the Health Care Finance Administration of the U.S. government which provides health care insurance to people aged 65 years or older.
An individual covered under a health care plan. They may be subscribers or subscribers' dependents.
Multisource brand drugs
Brand-name drugs which are distributed by more than one manufacturer and which also may have a generic drug counterpart available.
National Association of Boards of Pharmacy (NABP)
Each pharmacy is assigned a unique NABP number which differentiates it when transmitting claims. NABP is synonymous with "pharmacy ID".
National Committee on Quality Assurance (NCQA)
A not-for-profit organization that performs quality-oriented accreditation reviews of managed care plans. NCQA also develops HEDIS standards.
National Drug Code (NDC)
The unique, 11-digit NDC number assigned to each legend drug. The first five digits identify the manufacturer. The next four digits identify which product the drug is. The final two digits signify the package size.
A group of providers defined by the pharmacy benefit manager or health plan. Networks are linked via contractual arrangements. A physician network is sometimes referred to as a "panel." Anthem Prescription provides nationwide access to prescription drugs through the Anthem Rx Network Retail Pharmacy.
Network Retail Pharmacy
A national network of participating retail pharmacies which gives members access to both chain and independent pharmacies across the United States.
Products not included on your drug list/formulary, if applicable.
Non-sedating antihistamines therapeutic class
The therapeutic class of drugs that are used to treat various conditions, most commonly to provide relief of seasonal allergic rhinitis (hay fever).
Non-steroidal anti-inflammatory drugs (NSAID group)
The class of drugs that are typically used to treat arthritis, inflammation, and pain.
Off-label drug use
Use of a drug for purposes other than those originally approved by the FDA. For example, if a drug was originally approved for use as an anti-inflammatory, using it to treat cancer would be considered an "off label" use.
The time period during which a managed care organization allows individuals to apply for plan membership.
Over-the-counter (OTC) drugs
Drugs which may be purchased without a prescription.
A pharmacy which has entered into an agreement to provide prescription dispensing services to health plan members.
Pharmacy Benefit Manager (PBM)
A company that is dedicated to providing prescription benefits to health plan members.
Pharmacy and Therapeutics Committee (P&T Committee)
An Anthem committee comprised of practicing physicians and pharmacists which reviews medications for efficacy, effectiveness, and value. This committee continually monitors and updates our drug lists/formularies by reviewing new and existing medications and making recommendations to the health plans.
A provider who legally writes prescriptions for a member.
The written, telephoned, faxed, and/or approved electronic submission of a prescription drug order by a prescriber.
Primary Care Physician (PCP)
Usually the first doctor seen by a member. The primary care physician may treat a member directly or refer them to a specialist.
Certain prescription drugs (or the prescribed quantity of a drug) may require “prior authorization” before you can fill the prescription. Some drugs require prior authorization because they may not be appropriate for every patient or may cause side effects. Your doctor should have a current list of drugs requiring prior authorization. However, your doctor may call our referral number for authorization and information regarding these requirements. Prior authorization helps promote appropriate utilization and enforcement guidelines for prescription drug benefit coverage.
At the time you fill a prescription, your pharmacist is informed of the prior authorization requirement through the pharmacy's computer system and is instructed to contact your health plan. The health plan will review the request and communicate the approval criteria to the requestor. If additional information is needed, the pharmacist may contact your prescribing physician.
Your doctor may also request an exception to the prior authorization requirements, such as in instances in which you have an allergic or adverse reaction to the medication, or another documented reason that prevents you from following the prior authorization requirements.
A person or facility that provides health services to a member. Typical examples are physicians, hospitals, pharmacies, mail order pharmacies, nurses, etc.
A unique identification number assigned to each licensed physician by the federal Drug Enforcement Agency (DEA) that enables the physician to prescribe and dispense controlled substances.
Quality of care
Desired state of excellence in the provision of health care.
One of the criteria screened during the real-time point-of-sale edit process, refill-to-soon measures the percentage of a prescription which must be used before the prescription can be refilled. This assures that medications are not dispensed too frequently.
Retail chain pharmacies
A group of pharmacy stores under same management or ownership. Examples: CVS, Walgreens, Kroger, etc. The participating retail pharmacies available as part of our prescription drug benefit include most national chain pharmacies.
Single source brand
Brand-name drugs which are marketed under a registered trade name or trademark and are available from only one manufacturer. These products are generally patent-protected for a period of time.
The practice of beginning a course of treatment with an initial drug before using another drug therapy and progressing to more advanced therapy only if necessary. Step therapy may also recommend two therapies not be used simultaneously to avoid adverse outcomes.
Targeted therapeutic classes
Therapeutic drug classes that are carefully monitored and measured to assure appropriate drug therapy, cost management initiatives, and proper utilization.
Grouping of medications that are used to treat the same or similar conditions. Your drug list/formulary, if included in your coverage, contains drugs in every therapeutic drug class.
The practice of substituting one drug for another (with the health plan member’s consent) when both are thought to produce the same therapeutic effects.