Accuracy Percentage – Refers to the percentage of correct prescriptions filled by LDI’s mail order program.
Acute Medications – see Short Term Medications
AWP – Average Wholesale Price for brand and generic drugs.
Bio-injectable or specialty medication – High-cost, injectable, oral, infused or inhaled medications that are either self-administered or administered by a healthcare provider, and used or obtained in either an outpatient or home setting.
Claim History – A participant’s history of prescriptions filled through LDI’s benefit program; usually encompasses medication, quantity, fill date, location, physician, and approval or rejection status of the fill.
Claim Repricing – A system that identifies claims by HCPCS coding, allowing for accurate re-pricing of the medication, thereby allowing greater discounts over what is typically seen at the PPO level.
Co-payment – A dollar amount required of members in order to receive benefits.
Coordination of Care – The process by which participants are supported and implemented into the specialty pharmacy program, including contact with participants physician to obtain pertinent medical information, ensuring appropriateness of medication therapy, enrolling the patient in an automatic refill program when necessary and providing education and resources on medication administration and chronic conditions.
Data Management Tools – Tools, such as reporting, that are key to delivering the pharmacy benefit services needed to manage healthcare costs and optimize pharmacy benefit plans.
Disease Management – Refers to programs designed to enhance the well-being of a participant’s health, as well as their economic and personal lives, through wellness programs, health and lifestyle tools and coordination of care.
FDA – United States Food and Drug Administration
Flexible Billing – Billing services based upon a client’s needs.
Formulary – A list of drugs that a plan covers, which usually includes generic drugs, preferred brand and non-preferred brand-name drugs.
Formulary Management – Aggressive formulary management determines future plan costs, co-payment structure, member participation, drug utilization and rebate dollars.
Formulary Selection – An integral part of the strategic plan design is the selection of pharmaceuticals used within the plan. A committee of physicians, pharmacologists and pharmacists select drugs by therapeutic classification.
Generic or Generic Drug – Generic medications have the same active ingredient(s) as their brand-name counterparts and are equal in dosage, safety, strength, quality, performance and use.
Generic Substitution – Generic substitution is the administration of a drug product with the same ingredient(s) in place of a brand-name drug.
Health Envelope – An innovative web-based program offered by LDI to members that provides valuable health and lifestyle management tools.
Help Desk – Integrated call centers with highly trained customer service representatives providing service and attention to member and client needs.
HIPAA – Stands for the Health Insurance Portability and Accountability Act. A notice of privacy practice which describes how LDI may use and disclose PHI (protected health information) to carry out treatment, payment or health care operations, and for other specified purposes that are permitted or required by law. Review LDI’s HIPAA Notice.
HMO – A managed care organization that contracts with individuals, employers, physicians and the government to provide comprehensive healthcare services to enrolled members.
Infusion Services – See Home Infusion Therapy
Mail Order Services – Provide prescribed medications to participants via U.S. mail, or UPS, and is usually more cost effective when used for long term maintenance medications.
Mail Service Vendor – A facility used by a PBM to fill, dispense and mail prescriptions.
LDI owns and operates its own mail service facility.
Maintenance Medication or Long Term Maintenance Medications – Medications that are prescribed to treat long term conditions, such as high blood pressure or diabetes.
Non-Participating LDI network pharmacy – A pharmacy that is not within LDI’s network of retail pharmacies. Participants using a non-participating pharmacy will pay full price for their prescriptions.
Outpatient Services – A patient who receives therapy in a hospital or clinical setting.
Pharmacy Benefit Manager (PBM) – An organization that manages the pharmaceuticals benefit for the payer. A PBM provides many services designed to lower pharmaceutical costs for their clients, including: DUR, claims processing, retail pharmacy networks, formulary programs, mail service programs, physician profiling and education.
Plan Design – A plan designed to provide prescription drug benefits to participants by an employer or welfare fund, which includes specifications such as co-payments, days supply, retail and/or mail order services, deductibles, maximum allowable benefit, reimbursement, formulary management and specialty pharmacy services.
Pre-Certification – see Prior Authorization
Rebate – The reduced price of a drug obtained by LDI from the pharmaceutical manufacturer.
Retail Pharmacy Network – Retail pharmacies that have been contracted with a pharmacy benefit manager.
RxPortal – A secure online benefit service for members, allowing them to access information about their prescription drug benefits, locate a pharmacy nearest to them, order prescription refills online, retrieve co-pay estimates, view claim history and retrieve brand and generic drug information.
RxView – A secure, web-based application that provides employers with access to their employees' prescription benefit information. The program allows you to update member data such as eligibility, termination, contact information and identification information. The application also allows you to order new ID cards and view claim history.
Specialty Drug Formulary – A list of specialty pharmacy drugs that a plan covers.
Specialty Medication – High-cost, injectable, oral, infused or inhaled medications that are either self-administered or administered by a healthcare provider and used or obtained in either an outpatient or home setting.
Specialty Pharmacy Services – Services designed to provide bio-injectable, oral, infused or inhaled medications to individuals with chronic diseases and conditions.
Step Therapy – A program designed to work with physicians to consider all of the medications available to treat a disease or condition, taking into consideration medications that are well-established, safe and cost effective.
Therapeutic Substitution – The dispensing of a drug, when prescribed by a physician, that belongs to the same drug class and works in the body similar to the original drug requested. The drug dispensed is listed on the plan’s formulary and may be brand-name or generic and is often less expensive than the original drug requested.
TPA or Third Party Administrator – Refers to a company that administers many aspects of a plan including monitoring eligibility and claims.
Turnaround Time – Refers to the amount of time it takes to fill an order for a prescription medication and then mail the medication after LDI has received the prescription.
Union – An organization of workers and leaders designed to maintain or improve the conditions of their employment and benefits.