A list of drugs that are covered under a prescription drug plan. More commonly called a dpreferred drug list or PDL.
Many health insurance companies have created formulary lists to regulate what drugs they will cover or help pay for. If a member uses a drug not on their health
insurance plan’s formulary list, they will pay higher out-of-pocket costs. Also called a preferred formulary.
Formulary Reference File. A listing of drugs that Part D plan sponsors must utilize in the submission of Part D formularies.
Fraud, Waste, and Abuse. A comprehensive program designed to help drug benefit sponsors detect, correct, and prevent fraud, waste, and abuse.
The part of the Medicare plan where the member pays for prescription drugs. The plan does not pay. The gap occurs after you reach your initial coverage limit. It lasts until the expenses you pay add up to a certain amount. Also referred to as the Doughnut Hole.
Gross Drug Cost Above Out-of-Pocket Threshold. This field represents the gross drug cost paid to the pharmacy above the Out-of-Pocket threshold for a given PDE for a covered drug.
Gross Drug Cost Below Out-of-Pocket Threshold. This field represents the gross drug cost paid to the pharmacy below the Out-of-Pocket threshold for a given PDE for a covered drug.
A drug that is produced and distributed without patent protection. The generic drug may still have a patent on the formulation but not on the active ingredient.
A generic drug whose active ingredients are identical in chemical composition to its brand-name counterpart.
Generic Product Indicator
An indicator that will distinguish a product either priced as a generic drug or priced as a brand.
Generic Product Identifier. A Therapeutic Class maintained by Medi-Span® that defines pharmaceutically equivalent drug products. Products having the same 14-character GPI are identical with respect to active ingredients, dosage form, route, and strength.
Generic Sequence Number. Uniquely identifies a product specific to its agent, dosage form, and strength, and route of administration. It is not unique across manufacturers and/or package sizes. The digits which make up the GSN have no significance. Rather, the GSN is used to group generically equivalent pharmaceutical products.
Health Insurance Claim Number. The health insurance claim number is a number assigned to each Medicare beneficiary. This claim number is used for identification purposes when processing Medicare claims.
Health Insurance Portability and Accountability Act of 1996. A federal law that outlines the requirements that employer-sponsored group insurance plans, insurance companies, and managed care organizations must satisfy in order to provide health insurance coverage in the individual and group healthcare markets.
Health Plan Management System. A database of information on Medicare Part A and Part B recipients who are enrolled in coordinated care plans.
Initial Coverage Limit. This is the first part of a Medicare prescription drug plan. A member pays a set amount until the member and plan payments hit a certain total. Once this limit is reached, the terms change. Members may pay more as the plan moves to the coverage gap phase.
The cost of the drug product as stated on the drug claim, or as calculated by multiplying the quantity of drug dispensed times its unit cost. In simple terms, it is AWP less the contract pharmacy discount.
Ingredient Cost Paid
This field contains the amount paid to the pharmacy for the drug itself. Dispensing fees or other costs are not to be included in this amount except as allowed on nonstandard format claims.
LIS or LICS
Low income subsidy. Financial assistance that is available for people enrolled in Medicare or Medicaid programs with low incomes (below 150% of the Federal Poverty Line) and limited assets.
A lab information system (LIS) is a class of software that receives, processes, and stores information generated by medical laboratory processes. These systems often must interface with instruments and other information systems such as hospital information systems (HIS).