Pharmacy

The postal ZIP code associated with a drug-related entity, such as a dispensing pharmacy location or drug manufacturer address. Used in pharmacy network management and specialty drug distribution to identify geographic service areas and support pharmacy network adequacy reporting.

The fixed dollar amount a member is required to pay out-of-pocket for services associated with a defined treatment duration period, such as an extended care episode or duration-based benefit tier. Captured in claims and benefit administration systems to calculate member liability accurately.

The member cost-sharing amount applicable as of the coverage effective date for a specific benefit or service type. Used in health plan enrollment and claims adjudication to apply the correct copay obligation aligned with the member's benefit plan terms at the time coverage begins.

The fixed out-of-pocket cost a member is responsible for when receiving endocrinology specialist services, such as evaluation and management of diabetes, thyroid disorders, or hormonal conditions. Applied during claims adjudication based on the member's specialist tier benefit design.

The patient cost-sharing amount applied to a defined episode of care, representing a bundled or condition-specific care period such as a maternity episode or surgical episode. Used in value-based benefit designs and claims systems to calculate member liability across a continuous care event.

The fixed member cost-sharing amount required for evaluation and management services, such as physician office visits, consultations, or diagnostic assessments. Applied in medical claims adjudication to determine patient financial responsibility for evaluation services based on plan benefit design.

A prescription drug that is explicitly not covered under a health plan pharmacy benefit regardless of medical necessity, typically including drugs available over the counter, cosmetic medications, weight loss drugs, fertility treatments, and experimental or investigational therapies unless otherwise mandated by state law or contract. Excluded drug lists are disclosed in Summary of Benefits and Coverage documents and members may appeal or seek coverage through alternative benefit pathways.

The member out-of-pocket copay amount associated with services categorized under a specific patient experience or care program designation. Used in health plan benefit administration to apply cost-sharing rules for experience-rated or program-specific service categories during claims processing.

The date on which a prescription was dispensed by a pharmacy to a patient, used as the primary date for pharmacy claims analytics, medication adherence calculations, drug utilization review, and refill pattern analysis. Fill date is distinct from prescription written date and is the date used in proportion of days covered calculations to determine the start of each medication coverage interval in medication adherence measurement.

The member cost-sharing amount applicable to claims associated with a clinical finding, such as a diagnostic result or identified condition during a clinical assessment. Used in benefit adjudication systems to apply the correct patient liability when services are tied to a documented clinical finding.

The patient cost-sharing amount associated with a specific benefit form type or service category as defined in the health plan benefit structure. Used during claims adjudication to apply the correct copay based on the form or service classification assigned to the submitted claim.

A process allowing members or prescribers to request coverage of a non-formulary drug or a lower cost-sharing tier when the standard formulary alternative is clinically inappropriate for a specific patient due to contraindications, prior treatment failures, or other clinical circumstances. Formulary exceptions must be processed within defined timeframes under CMS and state regulations and approved when the requested drug is medically necessary and the formulary alternative is contraindicated.

A flag indicating whether a specific drug formulation, such as tablet, capsule, liquid, or injectable, is currently active and eligible within the pharmacy formulary or drug database. Used in pharmacy benefit management to control dispensing eligibility and formulary display of drug preparation types.

Indicates whether a specific drug formulation is currently active and available for prescribing or dispensing within the pharmacy system. Used to control formulary availability, prevent dispensing of discontinued preparations, and maintain accurate medication catalogs in pharmacy benefit management and clinical systems.

Stores the physical or mailing location associated with a specific drug preparation type, such as a compounding pharmacy or manufacturer site. Referenced in pharmacy and PBM systems to route drug orders, validate dispensing locations, and support regulatory compliance for controlled substance tracking.

The monetary value applied to modify the original price of a drug formulation in pharmacy claims or billing transactions. Captures price adjustments such as rebates, discounts, or corrections applied during adjudication, affecting the final reimbursement amount paid to the dispensing pharmacy.

The elapsed time since a specific drug formulation was introduced or compounded, used in pharmacy and clinical settings to assess stability, expiration risk, and regulatory compliance. Supports quality control workflows and helps identify formulations nearing the end of their approved shelf life or compounding period.

The maximum dollar amount a payer will reimburse for a specific drug formulation under a pharmacy benefit plan. Established through contracted rates or fee schedules, this value drives adjudication decisions and determines the difference between the billed charge and what the plan will pay.

Captures the monetary value tied to a specific drug preparation type, such as the cost of a compounded or branded formulation. Used in pharmacy benefit management, claims adjudication, and drug pricing tables to calculate reimbursement, patient cost-sharing, and formulary tier pricing in PBM and EHR systems.

Indicates the regulatory or formulary committee authorization state of a drug formulation, reflecting whether it has been reviewed and approved for inclusion on a formulary or for clinical use. Tracks states such as pending, approved, denied, or conditionally approved within pharmacy benefit management systems.