Pharmacy Terminology

2. A restriction on the amount or quantity of medication that is covered by the plan during a specific period.
4. A one-time, 30-day supply of a drug that plans must cover when an individual is in a new plan or when their existing plan changes its coverage.
7. A pharmaceutical drug that contains the same chemical substance as a brand name. Sale of these drugs are allowed once the patent on the original brand drug expires.
9. A list of prescription drugs a plan covers and at what tier.
10. Drugs considered to have a strong potential for abuse or addiction, but have a legitimate medical use.
12. A type of insurance in which the insured pays a share of the payment made against a claim.
15. An official contract that outlines what an insured is entitled to, and what they aren't insured for, under a health insurance policy.
16. A statement sent to a member which gives all of the details on what the plan covered, did not cover, how much money needs to be paid, and more. The EOB is generated when your provider submits a claim for the services the member received.
17. Occurs when patients pay for a portion of health care costs not covered by health insurance.
19. The amount paid out of pocket by the policy holder before an insurance provider will pay any expenses.
21. A drug plan formulary that divides drugs into groups.
23. A drug that is sold under a specific name or trademark that is protected by a patent.

1. This team generally reviews the pre-authorization requests from members and providers coordinating the care they receive. The goal is to make sure that patients get the care they need without wasting resources.
3. Drugs and medications that by law require a written order.
5. A drug sold directly to a consumer without the need for a prescription from a healthcare professional.
6. A group of medications used to treat the same condition of diagnosis.
8. An 11-digit identification number assigned to all drug products.
11. A payment made by a member in addition to that made by an insurer.
13. The formulary is usually divided into tiers or levels of coverage based on the type or usage of the medication. Each tier has a defined out-of-pocket cost that the patient must pay before receiving the drug.
14. A requirement to contact the plan before filling certain prescriptions. Prescribers may need to show that the drug is medically necessary for the plan to cover it.
18. A process where members must first try a less expensive drug to see if it works before the plan will agree to cover a more expensive drug.
20. A drug that is changed by combining, mixing, or altering ingredients to create a medication tailored to the needs of an individual patient.
22. The price a members pay for a policy, usually as a monthly payment.