Average Wholesale Price or AWP means the average wholesale price of a prescription drug published and updated by Medi-Span, or another nationally-recognized reporting service. (AWP also stands for Ain’t What’s Paid, due to the fact that AWP pricing can fluctuate based on many factors.)
Brand Drug (Medispan Definition) means a Covered Product where the Medi-Span Multi-Source Indicator for the Covered Product reported by Medi-Span contains an “M” (co-branded product), “O” (originator brand) or an “N” (single source brand) for the Covered Product on the date dispensed (except where the claim is submitted with a DAW code of “5.” In that case, it shall be considered a Generic Drug).
Business Associate means a person assisting a Covered Entity in connection with its payment, treatment or health care operations, as more fully defined in 45 CFR §160.103.
Coinsurance means that portion of the charge for Covered Products, calculated as a percentage of the charge, which is to be paid by Eligible Persons pursuant to Client’s Plan Guidelines (or for certain Participating Pharmacies, if less, the U&C of the Covered Products).
Coordination of Benefits means claims administration when Eligible Persons are covered by more than one pharmacy benefit plan.
Co-payment means a fixed dollar portion of the charge for Covered Products which is to be paid by Eligible Persons pursuant to Client’s Plan Guidelines (or for certain Participating Pharmacies, if less, the U&C of the Covered Products).
Covered Entity means a health plan, a health care clearinghouse or a health care provider, as more fully defined in 45 CFR §160.103.
Covered Products means those prescription drugs and ancillary devices and supplies that are covered under Client’s Plan Guidelines.
Deductible means a predetermined amount of money that an Eligible Person must pay before benefits are eligible for payment as indicated in Client’s Plan Guidelines. The deductible applies to each Eligible Person each contract year.
Dependent means an individual who satisfies all the eligibility criteria through a Cardmember necessary to receive pharmacy benefits under Client’s Plan and is identified by Client to Navitus in accordance with the provisions of this Agreement as eligible for such benefits. For purposes of clarification, any Eligible Person who is a “Cardmember,” as defined above, is not a “Dependent” for purposes of this Agreement.
Direct Reimbursement Claim means a request for reimbursement for the cost of one or more Covered Products dispensed by a pharmacy and submitted by a Participating Pharmacy, a Non Participating Pharmacy, or an Eligible Person in a pre-printed universal claim form.
ERISA means the Employee Retirement Income Security Act of 1974, and regulations promulgated thereunder, as amended from time to time.
FDA means the United States Food and Drug Administration.
Formulary means the list of FDA-approved Covered Products developed by Navitus’ Pharmacy and Therapeutics Committee, subject to Client’s Plan Guidelines and coverage decisions.
Generic Drug means a Covered Product for which there is an approved application under§ 505(j) of the Federal Food Drug and Cosmetic Act (21 USC 355(j)) and the Medi Span Multi-Source Indicator for the Covered Product is a “Y” on the date dispensed. Claims submitted with a Multi-Source Code, as defined by Medi-Span, of “O” and also submitted with a DAW code of “5” shall also be considered a Generic Drug. If a drug product approval is based upon an abbreviated new drug application (ANDA), that drug is a Generic Covered Product. Single source Generic Covered Products are included in the definition of “Generic Covered Products.”
HIPAA means the Health Insurance Portability and Accountability Act of 1996, and regulations promulgated thereunder, as amended from time to time.
Mail Service Pharmacy means a pharmacy dispensing covered products where prescriptions are filled and delivered to Eligible Persons via the United States Postal Service, United Parcel Service or other delivery service.
Maximum Allowable Cost (“MAC”) means the maximum allowable cost determined by Pharmacy Benefit Manager or other processing entity based upon review and analysis of current pricing in the marketplace.
Pass-Through means that:
- All Claims are invoiced to Client at the net amount a Pharmacy Benefit manager pays the Participating Pharmacy for such Claims
- Rebates are provided to Client in accordance with a process that the Pharmacy Benefit Manager does not retain any Rebates or any other direct financial benefits from drug manufacturers or pharmacies, and pays all such amounts to the Client.
Plan Guidelines means a description of aPlan related to pharmacy benefits and limitations thereto, including the framework of policies, interpretations, rules, practices and procedures applicable to such benefits.
PPACA means the Patient Protection and Affordable Care Act and the Health Care Education and Reconciliation Act of 2010 and their accompanying regulations, as amended from time to time.
Prior Authorization means a prospective review to verify that certain criteria required by Client are satisfied for specific Covered Products prior to processing the claim for such Covered Products.
Protected Health Information or PHI has the meaning set forth in 45 CFR §164.501 and includes individually identifiable health information related to the physical or mental health or condition, the provision of health care, or the payment for the provision of health care to an Eligible Person or otherwise deemed confidential under federal or state law.
Rebates means rebates or discounts received by Pharmacy benefit manager pursuant to a contract with a pharmaceutical manufacturer, and directly attributable to the Formulary and Covered Product utilization by Eligible Persons.
Specialty Pharmaceuticals means those biotech and other Covered Products identified as specialty pharmaceuticals from time to time.
*Specialty Drugs may be defined differently by different Pharmacy Benefit Management Organizations.
Specialty Pharmacy means a pharmacy that has entered into an agreement with the Pharmacy Benefit Manager to dispense Covered Products, including Specialty Pharmaceuticals to Eligible Persons.
Transparency in Pharmacy Benefits (CCRX definition): To be 100 % Transparent a Pharmacy Benefit Manager should :
- Allow for full visibility into pharmacy provider contracts
- Allow for full visibility into pharmaceutical manufacturer contracts
- Provide a rebate report showing where every dollar was achieved at the drug level
Usual and Customary Price or U&C means the retail price charged by the dispensing Participating Pharmacy Location for a particular Prescription Drug in a cash or uninsured transaction, on the date such Prescription Drug is dispensed by such Participating Pharmacy Location, exclusive of: (i) sales tax; (ii) discounts claimed, and (iii) discounts provided for prescription drug savings card or other similar discounts claimed.
Wholesaler Acquisition Cost or WAC means the wholesale acquisition cost pricing data for a given pharmaceutical product, as published by Medi-Span or another nationally recognized drug database reporting service.
Zero Balance Claims are claims in which the participant or member pays the entire cost of the prescription, and the group or payer has no financial liability.