Members

Glossary

Appeal

The process by which a member reports dissatisfaction with a documented decision from a response to a grievance or a prior authorization.

Brand Name Drug

A drug that has a trademark and is, or previously was, protected by a patent.

Copayment (Copay)

The portion of the medication cost that the member is responsible for paying when filling a prescription at a participating network pharmacy.  The copay amount may vary based on which type of drug is chosen and the structure of the plan’s benefits.

Drug Compounding

Compounded drugs are drugs that have been combined according to a unique recipe to produce a formulation that is not readily available or approved by the Food and Drug Administration, to suit a particular patient’s needs.

 

Drug Utilization Review (DUR)

The process of evaluating prescribers’ prescribing patterns and/or patient drug utilization to determine the appropriateness of therapy.

Experimental/Investigational Drugs

Prescription drugs being tested in clinical trials that may or may not be approved for sale by the U.S. Food and Drug Administration.

Formulary

The list of drugs covered by a plan sponsor.  Also known as a Preferred Drug List (PDL).

Generic Drug

Chemical equivalent of a brand name drug. Generics are typically less expensive, contain the same active ingredients as a brand name drug, and produce the same outcomes as their brand name counterparts.

 

Grievance

A complaint submitted to the pharmacy benefit manager by, or on behalf of, the affected member regarding a problem or issue.

Injectable

Prescription drugs that are administered via injection. Typically, injectable drugs require careful storage and administration by either the member or a health care professional.

Lifestyle Drugs

Drugs that are not medically necessary but used to improve the quality of life.

Mail Service Provider

A pharmacy that dispenses medication through a shipping service to the home or office of the member receiving the prescription.  This service is typically used by individuals who take one or more medications over an extended period of time.

 

Maintenance Medications

Drugs used to treat chronic diseases or conditions, and taken on a long-term basis.

 

Multi-source Brand

A drug product manufactured by more than one company or source. Multi-source drugs are those that are available both as the brand-name drug, and as generic equivalents or generic alternatives.

Non-formulary Drugs

Drugs not included on a plan's drug list or formulary.

 

Nonpreferred Brands

Brand name drugs not included on a plan's formulary.

Over-The-Counter (OTC) Drug

Drugs approved by the U.S. Food and Drug Administration that do not require a prescription to be purchased.

Pharmacy Benefit Manager (PBM)

Organization dedicated to providing prescription benefit management services. A full-service PBM like Envolve Pharmacy Solutions maintains eligibility, adjudicates prescription claims, provides clinical services, contracts and manages pharmacy networks, and provides management reports.

 

Pill Splitting

Cutting prescription medications in half to double the number of days’ supply from one prescription.

 

Preferred Brands

Brand-name drugs included on a plan's formulary.

 

Preferred Drug List (PDL)

The list of drugs covered by a prescription plan. Also known as a formulary.

 

Prior Authorization (PA)

A process where additional information must be provided or criteria must be met before certain medications can be dispensed. The criteria for which drugs require a PA are established by the plan sponsor.

Quantity Limits

Limit on the number of pills or dosages allowable per claim.

Single-source Brand

A drug product manufactured by one company or source. Single source drugs are those brand-name drugs that do not have a generic equivalent or generic alternative.

 

Specialty Drugs

Drugs manufactured through biologic processes to treat chronic, complex or life-threatening conditions.

 

Specialty Pharmacy Benefit

Coverage of drugs manufactured to treat chronic, complex or life-threatening conditions.

 

Step Therapy

Treatment guidelines used to recommend drug therapy beginning with the least expensive therapy. More expensive therapies are only used when the patient fails to respond to the first-line drug or after a Prior Authorization.

Therapeutic Substitution

Dispensing of a drug that is therapeutically equivalent to the originally prescribed drug.

 

Tier

Drugs on a formulary are grouped in different categories, or tiers, to represent copayment amounts. Lower drug tiers are associated with lower drug costs.