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