321-Exam 1

Generic Substitution

substitution of drug products that contain the same active ingredient or ingredients and are chemically identical in strength, concentration, dosage form, and route of administration to the drug product prescribed.

Policy

a broad general statement that describes the goals and purposes of a course of actions

Therapeutic Alternative

Drug products with different chemical struc­tures but of the same pharmacologic or therapeutic class and usually have similar therapeutic effects and adverse­ reaction profiles when administered to patients in therapeutically equivalent doses.

Procedure

The specific stepwise actions to be taken

Therapeutic Interchange

Authorized exchange of therapeutic alter­natives in accordance with previously established and approved written guide­lines or protocols within a formulary system.

Therapeutic Substitution

The act of dispensing a therapeutic alternative for the drug product prescribed with prior authorization of the prescriber.

The P&T committee

Responsible for administering the formulary system

Prior Authorization Criteria

Require the submission and approval through the telephone, an online portal/website, or written coverage request for the health plan to cover the drug

Quantity Limits

Establishes limits on the amount of medication a patient may receive during a designated period or in a single refill, such as a 30-, 60-, or 90-day supply

Formulary Coverage Restrictions

Determine the medications that are included within a formulary

Narrow Pharmacy Networks

Encourage or require patients to use designated pharmacies or dispensing channels

Drug Utilization Review (DUR)

Ongoing review of the prescribing, dispensing, and taking of medications.

Step Therapy

More expensive drugs are not authorized unless patients do not respond to less expensive therapeutic alternatives.

Disease management:

Identification and caring for segments of the enrolled population with specific chronic conditions (eg, asthma, diabetes)

Outcomes measurement:

A subset of the quality measures that deal with the patient’s functional health status, morbidity, and mortality levels

Utilization management:

The evaluation of the medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities

Referral authorization:

The process by which the enrollee’s PCP must authorize a referral to see a specialist or obtain a specific diagnostic test.

Demand management:

Tools used to moderate a patients’ insistence for (especially expensive) healthcare services.

Case management:

A subset of utilization management that includes the utilization review of high-cost patients

Health

a state of complete physical, mental, and social wellbeing

Care

efforts made to maintain or restore physical, mental, or emotional wellbeing, by trained and licensed professionals

System

interdependent parts that are interconnected by input, throughput, and output to create one unified and designed process

UHC

all people have access to full range of quality health services they need, when and where they need them, and without financial hardship; covers full extent of essential health services from health promotions to prevention, treatment, rehab, palliative care

First fail protocols

require demonstration that a generic drug, lower treatment, or lower cost drug fails to work for the patient before plan covers more expensive med or treatment

Mail order criteria

requires a higher copay if the patient obtains the drug from a retail pharmacy versus the PBM’s mail order pharmacy

Formulary system

ongoing process through which a healthcare organization establishes policies regarding the use of drugs

Open formulary

list of recommended drugs with no requirements concerning use and drug benefit coverage

Closed/restricted formulary

only a limited number of agents are available with certain parameters related to use and drug benefit coverage