FInancial Issues

Pharmacy Benefit Managers

Pharmacy Benefit Managers

A company that administers drug benefit programs.

Maximum Allowable Cost

The maximum price per tablet an insurer or PBM will pay for a given product.

UCR or U&C

The maximum amount of payment for a given prescription determined by the insurer to be a usual and customary price.

Online Adjudication

Pharm Tech uses a computer to determine the appropriate third-party’s exact coverage for each prescription.

co-insurance

an agreement between the insurer and the insured to share costs.

co-pay

patient pays a portion of the medications price and the insurance company is billed for the remainder

dual co-pay

lower co-pay applies to prescription filled with generic drugs and higher co-pay applies to prescriptions filled with brand name drugs with no-generic.

deductible

a set amount that must be paid by the patient for each benefit period before the insurer will cover additional expenses.

What are 3 Types of Managed Care Programs?

HMOs, POS, PPOs

HMOs

a network of providers who are either employed by the HMO or have signed contracts to abide by the policies of the HMO. Often Require a generic substitution.

POS

Programs are a network of providers contracted by the insurer. Patients will choose a primary care physician and is part of the insurers network.

PPOs

Often the most flexible and offers the most flexibility. Often reimburse expense incurred outside of their participating network. Often require a generic substitution.

Coordination of Benefits

When spouses share a health insurance plan. Maximum coverage for healthcare expense through both health insurance plans but does not exceed 100% of the total costs.

Medicare

Federal Program administered by the centers of Medicare and Medicaid services covering people ages 65 or older, as well as people under 65 with kidney failure.

Medicaid

A Federal-state program for eligible patients with low income.

VA

Provides benefits for veterans, covering prescriptions covered by VA doctors and filled.

TRICARE

Provides healthcare benefits for eligible uniformed service members.

CHAMPVA

The Civilian Health and Medical Program of the Department of Veteran Affairs.

Workers Compensation

Established procedure for compensation for employees accidentally injured on the job.

Rejected Claims

Common reason for third claim rejections

• invalid sex

• invalid person code

• patient not covered

• NDC not covered

• invalid days supply

CMS-1500 Form

The standard form used by health-care providers for service including disease state managment services. CPT codes, calls for MTM, Physician and Pharmacists.

Universal Claim Form

Standard claim form accepted by many insurers, signed by the pharmacists.

CMS-10114 Form

Standard 6 -page form used by healthcare provides to apply for an NPI.

Medication Therapy Management

Services provided to some medicare beneficiaries who are enrolled in medicare Part D and who are taking multiple medications or have certain diseases.