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CMB-Chapter 9

CMB - Chapter 9 - Managed Care Rxs

QuestionAnswer
PPO Preferred provider organization
HMO health maintenance organization
MCO mananaged care organizations
PBM pharmacy benefit manager
drug ingredient cost refers to .... the price the pharmacy dept. pays for the medication
% of the drug product's published list price ia also known as... average wholesale price (AWP)
MAC maximum allowable cost
MAC is ... an estimate of the cost of a generic equivalent and max amount the payer will pay for a certain drug product
patient cost sharing is... designed to make patients more cost conscious & usually take the form of copayments, or deductibles & coinsurance
POS point of sale
formularies are... lists of meds that are covered or excluded from coverage
a daw provision... allows pharmacies to be reimbursed for multiple-source brand-name drugs under some circumstances
DAW 0 = no product selection indicated - product selection is not an issue - default
DAW 1 = sub NOT allowed by prescriber - product is to be DAW
DAW 2 = sub allowed, patient requested Brand product to be dispensed - generic sub is permitted
DAW 3 = sub allowed, Rph selected Brand product to be dispensed - generic sub is permitted
DAW 4 = sub allowed, generic drug not in stock
DAW 5 = sub allowed, brand drug dispensed as generic
DAW 6 = Override
DAW 7 = sub not allowed, brand drug mandated by law
DAW 8 = sub allowed, generic drug not avail. in marketplace
DAW 9 = Other
DUR drug utilization review
Most PBM's use DUR to monitor patterns of prescribing, dispensing and usage of prescription drugs
Retrospective DUR review of rx claims databases well after rxs have been dispensed
Prospective DUR occurs before rx is dispensed
a rx that has been filled, billed & adjudicated needs to be reversed or "unbilled" when a patient does not receive the rx is called claim reversal
Created by: cbowers101
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