PHCS Exam 1 Review

iron triangle

quality, access, cost

access

who can get the care when it is needed

Beveridge Model

socialized medicine that includes everyone and is covered by Texas

Bismarck Model

decentralized healthcare that requires private health insurance and receives money from employers and patients

National Health Insurance

the model where healthcare is funded and standardized by the government

wholesale distributor

the company that sells drug products to the pharmacy

Cencora, Cardinal Health, McKesson Corp.

vertical alignment

the merging of different companies in the healthcare chain into a single organization

usual and customary price (U&C)

the retail price charged by a pharmacy in a cash or uninsured transaction

average wholesale price (AWP)

a widely known average of the price of the drug that is not accurate

wholesale acquisition price (WAC)`

the base price of a drug to wholesale companies from manufacturers

average manufacturer price (AMP)

the actual cost between manufacturer and wholesaler that is determined once all transactions are complete

national average drug acquisition cost (NADAC)

the national average cost for retail pharmacies that is given on a voluntary basis

API

the chemicals used to manufacture pharmaceutical drugs

FDA

the organization responsible for ensuring that drugs are safe and effective

biosimilar

a biological product that is approved based on a showing that it is highly similar to an already-approved product

4

the number of phases in drug development

NDC #

a 10 digit unique drug identifier that includes the labeler, product, and the package code

patent

allows the holder to exclude others from making, using, selling, or importing the claimed invention, but does not give the holder the right to do those things

20

the amount of years a patent last

evergreening

the method of extending exclusivity to a patent by altering different aspects of the drug

adjudication

when a claim is sent to a PBM that determines whether the drug is covered/can be filled for the patient

health insurance

a contract that requires a health insurer to pay some or all of a patient’s healthcare costs in exchange for a monthly premium

public insurance

insurance that is partially or wholly paid by society

Part D

the portion of Medicare that covers prescription drug costs

deductible

the amount that must be paid out of pocket before an insurer will pay any expenses

co-pay

a fixed payment for a covered service that is paid when an individual receives the service

coinsurance

the percentage of the bill paid by an individual given they have met any deductibles

catastrophic cap

the maximum out-of-pocket expense for a patient during a define period of time

DIR fee

a direct or indirect remuneration fee that accounts for factors that change the final payment

PBM

a third-party administrator of prescription drug programs

PBM responsibilities

developing/maintaining formulary

contracting with pharmacies

negotiating discounts and rebates with manufacturers

processing and paying claims

formulary

a list of generic and brand name prescription drugs covered by a health plan

CMS Rating

a 5 star rating system that determines how good a plan is

Quality Bonus Payments

payments from CMS to large Medicare Advantage Plans that have 4+ star ratings

Pay for Performance

bonuses for pharmacies based on performance

chargeback

the amount paid to the wholesaler if the manufacturer has a contract with the pharmacy that is lower than the WAC

maximum allowable cost (MAC)

the cost set by the PBM and agreed to by network for generic drugs with many manufacturers