Pharmacy Terms, Acronyms, and Definitions
TERM |
ACRONYM or ABBREVIATION |
DEFINITION |
A/B Rated | Drug products made by different distributors and/or re-packagers that are considered therapeutically equivalent based on demonstrated bioequivalence. | |
Abuse | Incidents or practices that are inconsistent with accepted medical, business, or fiscal procedures. | |
Adjudication Cycle | System processing of claims at the point where a decision has been made to pay, deny or suspend. | |
Allowable Charge | Specific dollar amount of a medical claim Medicaid will pay. | |
Appeal | Process for reconsideration of a denied claim. | |
Authorization | Official approval for action taken for, or on behalf of, a Medicaid client. This approval is only valid if the client is eligible on the date of service. | |
Authorized Prescriber | Physician, osteopath, dentist, nurse, physician assistant, optometrist, naturopath, or other person duly authorized to prescribe drugs. | |
Average Manufacturer Price (AMP) | AMP | Average price paid to manufacturers by wholesalers for drugs distributed to the retail pharmacy. |
Average Wholesale Price (AWP) | AWP | Average of list prices charged by wholesalers to pharmacies. |
Bank Identification Number | BIN | Bank Identification Number is the identifier number for the payer. |
Brand Name | Proprietary or trade name selected by the manufacturer and placed upon a drug, its container, label, or wrapping at the time of packaging. | |
Center for Medicare and Medicaid Services (CMS) | CMS | Administers the Medicare and Medicaid programs. Formerly the Healthcare Financing Administration (HCFA). |
Change Healthcare | CHC | Wyoming Medicaid Pharmacy Benefit Manager beginning May 28, 2009 |
Chemical Name | The chemical name is a proper scientific name for an ingredient of a product. | |
Claim | Information submitted to insurers requesting payment for covered services. | |
Client | A person who has been determined eligible for Medicaid. | |
Compound Drug | A prescription drug prepared by a pharmacist using at least two or more active ingredients. | |
Compounding | Combining two or more active ingredients or adjusting therapeutic strengths in the preparation of a prescription. | |
Co-payment | Participant’s financial responsibility for a prescription assigned by Medicaid. Unless exempt, clients must pay $3.65/prescription for non-preferred brand-name drugs, or $3.65/prescription for preferred brand-name drugs, or $0.65/prescription for generic drugs. Exempt clients include residents of a nursing facility or in swing beds, pregnant clients, clients under the age of 21, family planning services, emergency services, American Indians, Alaskan Natives, or hospice services. | |
Date of Service (DOS) | DOS | The calendar date on which a specific medical service is performed. |
Day Supply | DS | Day supply of tablets, capsules, fluids (cc’s), etc., prescribed for the client. Day supply is the total number of days a patient’s prescription lasts when taken as directed, not the duration of treatment. |
Device | Equipment or apparatus used to remedy or compensate for a physical deficiency, e.g., a prosthetic device. | |
Dispense As Written (DAW) | DAW | Codes to be used by providers to explain the dispensing of a brand-name product instead of a generic one. |
Dispensing Fee | Amount of Medicaid reimbursement allowed by the OPS as payment for the service of dispensing any prescribed drug. Current dispensing fee is $5.00. | |
Division of Healthcare Financing | The Administrator that serves as the state Medicaid director with responsibility for oversight and technical assistance provided to the divisions that administer Medicaid within the Department of Health. | |
Drug Efficacy Study Implementation (DESI) | DESI | Drugs determined by the FDA as lacking substantial evidence of effectiveness. If the index is low, the drug is classified as “less than effective”. |
Drug Enforcement Administration (DEA) Number | DEA Number | Federal registry number used to identify a prescriber. |
Drug Utilization Review | DUR | Program designed to measure and assess (prospective and retrospective) the proper use of outpatient drugs in the Medicaid program. Primary objective of the DUR systems are to improve the quality of care and to assist in containing healthcare costs. Prospective DUR is a system within the Pharmacy point-of-sale (POS) system that assists pharmacy providers in screening selected drug categories for clinically important potential drug therapy problems before the prescription is dispensed to the client. Retrospective DUR screens after the prescription has been dispensed to the client through drug profiling and peer grouping. |
Dual Eligible | Medicaid clients who are also eligible for health benefit under Medicare or other public-sponsored health program. | |
Durable Medical Equipment (DME) | DME | Medical equipment used repeatedly in the treatment of illness and injury. These items may be reusable, such as walkers or wheelchairs. |
Federal Drug Rebates | Payment made by pharmaceutical manufacturers to the states to receive Federal matching funds for drugs dispensed to Medicaid clients. | |
Federal Upper Limit (FUL) | FUL | Maximum allowable cost established by CMS for certain prescribed drugs. The concept of the upper limits program is to achieve savings by taking advantage of the current market prices.Federal Upper Limit (FUL): Amount established by the Centers for Medicare and Medicaid Services (CMS), U.S. Department of Health and Human Services, as the maximum amount for payment for a multiple source drug in a State Medicaid Program. Until Spring 2007, a State’s total drug program payments for multi-source drugs could not exceed, in the aggregate, an amount established by CMS that is equal to 150 percent of the published price for the least costly therapeutic equivalent (using all available national compendia). After Spring 2007, the FUL will be calculated at 250 percent AMP (computed without regard to prompt pay discounts extended to wholesalers). Until passage of the DRA, FULs could not be established until there were at least three equivalent drugs (the original brand name drug and two generics) on the market. After Spring 2007, FULs will be established once there is a second equivalent on the market. |
Fiscal Agents | The Medicaid fiscal agent is under contract to certify providers, process and pay claims, answer provider and client questions, issue identification cards to client, and publish information for providers and client. Wyoming’s pharmacy fiscal agent is GHS. | |
Fill Date | Date a prescription was filled. | |
Food & Drug Administration (FDA) | FDA | United States Department of Health and Human Services responsible for regulating food, dietary supplements, drugs, biological medical products, blood products, medical devices, radiation-emitting devices, veterinary products, and cosmetics in the United States. |
Fraud | An intentional deception or misrepresentation that someone makes, knowing it is false, that could result in the payment of an unauthorized benefit. | |
Generic Drug | Identical bioequivalent to a brand name drug in dosage form, safety, strength, route of administration, quality, performance, characteristics, and intended use. Generic drugs usually cost less than brand-name drugs and are required by the Food and Drug Administration (FDA) to be as safe and as effective as the brand-name drug. | |
Generic Name | Official title of a drug or drug ingredients published in the latest edition of a pharmacopeia or formulary. | |
Health Insurance Portability and Accountability Act (HIPAA) | HIPAA | A federal law in which the primary goal is to make it easier for people to keep health insurance, protect the confidentiality and security of healthcare information and help the healthcare industry control administrative costs. |
Healthcare Common Procedure Coding System (HCPC) | HCPC | Set of healthcare procedure codes based on the American Medical Association’s Current Procedural Terminology (CPT). |
International Classification of Diseases-10th Revision, Clinical Modification (ICD-10 CM) |
ICD-10 | Nomenclature for medical diagnoses required for billing. |
J-CODES | A subset of the HCPCS Level II code set with a high-order value of “J” that has been used to identify certain drugs and other items. | |
Legend Drug | Any drug that requires a prescription under federal code 21 USC 353(b). | |
Maintenance Drug | Drugs furnished to an individual with a chronic illness or condition. The Department designates drugs as maintenance drugs based on therapeutic value, clinical consultation with practitioners, and applicable CMS guidelines. | |
Medicaid | Title XIX | Medical assistance program authorized under Title XIX of the Social Security Act. Program provides healthcare coverage to low-income families with children, pregnant women, disabled people, and the elderly. |
Medical Supplies | Disposable, semi-disposable, or expendable medical supplies. This does not include durable medical equipment, oxygen, or oxygen supplies. | |
Medicare | Health insurance program for the aged and disabled under Title XVIII of the Social Security Act. | |
Multi-Source Brand Drug | A brand drug for which the patent has expired. | |
National Association of Board of Pharmacies (NABP) | NABP | Independent, international, and impartial association that assists its member boards and jurisdictions in developing, implementing, and enforcing uniform standards for the purpose of protecting the public health. https://nabp.pharmacy/ |
National Council for Prescription Drug Programs (NCPDP) | NCPDP | Entity creates and promotes standards for the transfer of data to and from the pharmacy services sector of the healthcare industry. https://www.ncpdp.org/ |
National Drug Code (NDC) | NDC | Eleven-digit code assigned to each drug. The first five numbers indicate the labeler code (CMS assigned), the next four numbers indicate the drug and strength (manufacturer assigned), and the remaining two numbers indicate the package size (manufacturer assigned). |
National Provider Identifier (NPI) | NPI | Unique identification number for covered healthcare providers. Under HIPAA, NPIs will be used in administrative and financial transactions.Click here for the NPI Registry website |
Non-Rebatable Drugs | Drugs manufactured or distributed who have not signed a drug rebate agreement with the federal Department of Health and Human Services. | |
Orange Book Code | OBC | Orange Book Code (OBC) identifies the therapeutic equivalency ratings assigned to each approved prescription product according to the FDA’s Approved Drug Products with Therapeutic Equivalence Evaluations. |
Over-the-Counter (OTC) Drug | OTC | Non-legend drugs that do not require a prescription before they can be dispensed. |
Pharmacist | A person licensed to practice pharmacy by the Wyoming State Board of Pharmacy or a similar board or agency in another state. | |
Pharmacy | An entity licensed to operate a pharmacy by the Wyoming State Board of Pharmacy or a similar board or agency in another state. | |
Pharmacy Services | PS | Oversees Medicaid Pharmacy Prescription Program and other state programs. |
Pharmacy & Therapeutics Committee (P&T) | P&T | A committee that is comprised of physicians, pharmacists and a nurse practitioner all practicing in their respective fields in Wyoming. The purpose of the committee is to enhance quality of patient care by assuring appropriate drug therapy, optimal patient outcomes, and education for healthcare providers. |
Point-of-Sale (POS) | POS | Pharmacy claims processing system capable of adjudicating claims on-line. |
Preferred Drug List (PDL) | PDL | A list of preferred and non-preferred pharmaceutical substances within a specific therapeutic classes designed to maximize clinical and economic benefits as determined by the Department in consultation with the Pharmacy and Therapeutics Committee. |
Prescription | Rx | A written, faxed, or electronically prescribed direction from a physician to a pharmacists for the preparation and use of a medication or medical device. |
Prior Authorization (PA) | PA | Approval process required before certain services or supplies are paid by Medicaid. Prior authorization must be obtained before providing the service or supply. |
Single-Source Brand | A brand drug for which the patent has not expired and is not a co-branded drug. | |
State Maximum Allowable Cost (SMAC) | SMAC | State maximum allowable cost for drug products established by Pharmacy Services. Pharmacy Services is contracted with Goold Health Systems (GHS) to provide assistance in establishing and maintaining the SMAC program for pharmaceuticals. |
Supplemental Drug Rebate | Payment from a pharmaceutical manufacturer negotiated by the state, in addition to the Federal rebate. | |
Therapeutically Equivalent | Drug products with the same efficacy and toxicity when administered to an individual in the same dosage regimen. | |
Third Party Liability (TPL) | TPL | The legal obligation of a non-Medicaid insurers to pay part or all of the expenditures for medical assistance furnished under a Medicaid state plan. |
Usual and Customary | The fee that a provider most frequently charges the general public for service or item. | |