Pharmacy

A 14-digit hierarchical drug classification code developed by Medi-Span identifying the generic equivalent group of a drug product across all manufacturers and package sizes, enabling formulary management, drug utilization review, and pharmacy analytics at the generic ingredient level regardless of brand name or NDC code. GPI codes allow health plans to apply formulary policies and quantity limits consistently across all NDC codes representing the same drug ingredient, strength, and dosage form.

The dispensing of a bioequivalent generic drug in place of a prescribed brand-name drug when a generic equivalent is available and the prescriber has not indicated dispense as written, based on state pharmacy practice laws permitting automatic generic substitution. Generic substitution is the most cost-effective pharmacy benefit management strategy with generic drugs typically costing 80-85% less than brand-name equivalents while producing the same therapeutic outcomes.

The fixed out-of-pocket dollar amount a health plan member owes per geriatric care encounter, including comprehensive geriatric assessments, elder care consultations, and age-related chronic condition management visits. Applied during claims adjudication per the member's specific benefit plan cost-sharing structure.

The fixed out-of-pocket dollar amount a health plan member must pay per service encounter under a specific group benefit plan, such as an employer-sponsored or union group contract. Applied during claims adjudication to reflect the cost-sharing terms negotiated at the group contract level for the member's enrolled plan.

The fixed out-of-pocket dollar amount owed by the financially responsible party designated on a patient account, who may or may not be the patient themselves. Used in patient financial services and billing systems to correctly assign and collect cost-sharing obligations from the individual legally responsible for the account balance.

The fixed out-of-pocket dollar amount assigned to services or treatments rendered in accordance with established clinical practice guidelines. Used in health plan benefit design to apply differentiated cost-sharing that incentivizes members to receive evidence-based, guideline-compliant care as defined within the plan's clinical policy framework.

The fixed out-of-pocket dollar amount a health plan member owes for a service or supply billed under a specific Healthcare Common Procedure Coding System code. Applied during claims adjudication to assign member cost-sharing based on the HCPCS Level I CPT or Level II code reported on the medical or durable medical equipment claim.

The fixed out-of-pocket dollar amount a health plan member owes for a procedure involving a surgically placed medical device, such as a pacemaker, cochlear implant, or joint prosthesis. Applied during claims adjudication based on the implant-specific benefit tier defined within the member's health plan cost-sharing structure.

The fixed out-of-pocket dollar amount associated with services flagged by a specific quality or utilization indicator within a health plan's benefit or care management program. Used in value-based benefit design to track and apply cost-sharing rules to services identified through clinical quality measurement criteria.

The amount paid by a pharmacy benefit manager or health plan to a pharmacy for the drug product itself, distinct from the dispensing fee and excluding member cost-sharing amounts. Ingredient cost is typically based on a benchmark drug price such as average wholesale price or wholesale acquisition cost minus a negotiated discount. Ingredient cost is the largest component of total pharmacy reimbursement and the primary lever for pharmacy network cost management.

The fixed out-of-pocket dollar amount a health plan member is responsible for when a medical instrument or diagnostic device is used during a covered procedure or examination. Applied during claims adjudication to reflect cost-sharing obligations tied to instrument-based services within the member's benefit plan.

The amount a health plan member pays out-of-pocket for insulin prescriptions, subject to ACA requirements limiting insulin cost-sharing to $35 per month for Medicare Part D plans. Insulin cost-sharing reduction is a significant health equity and clinical quality initiative given the critical importance of insulin adherence for diabetes management and the disproportionate financial burden of insulin costs on low-income diabetic members.

The fixed out-of-pocket dollar amount assigned to a health plan member based on the specific insurance carrier or plan type through which their coverage is administered. Used in claims adjudication and benefit configuration to apply carrier-specific cost-sharing rules that reflect contractual terms between the insurer and the health plan.

The fixed out-of-pocket dollar amount a health plan member owes for a specific clinical intervention such as a therapeutic procedure, preventive treatment, or disease management service. Applied during claims adjudication to enforce cost-sharing obligations tied to intervention type as defined in the member's benefit plan structure.

The fixed out-of-pocket dollar amount a health plan member is required to pay for services related to the diagnosis or management of a documented food, drug, or environmental intolerance. Applied during claims adjudication when the encounter or prescription is associated with a non-allergic adverse response condition on the member's health record.

A specialty drug distributed through a restricted network of specialty pharmacies selected by the pharmaceutical manufacturer based on their ability to provide specialized patient support services, clinical monitoring, and compliance with Risk Evaluation and Mitigation Strategy requirements, rather than being available through all retail or specialty pharmacies. Limited distribution networks enable manufacturers to control drug safety monitoring and must be navigated by health plans in specialty pharmacy network contracting.

A pharmacy specializing in providing prescription drugs and pharmaceutical services to residents of skilled nursing facilities, assisted living facilities, and other long-term care settings, using unit-dose and blister pack dispensing systems designed for institutional medication administration. Long-term care pharmacies provide medication management services including consultant pharmacist reviews and specialized packaging and are reimbursed differently under Medicare Part D.

A pharmacy that dispenses medications through mail delivery rather than at a retail location, typically offering 90-day supply fills at lower cost-sharing than retail pharmacies to encourage use for chronic maintenance medications. Mail order pharmacy utilization is tracked as a pharmacy operations metric and is promoted through benefit design incentives such as reduced copayments for mail order fills compared to retail fills of the same chronic medication.

The fixed out-of-pocket dollar amount a health plan member owes for a mammography imaging service, including screening and diagnostic breast imaging procedures. Applied during claims adjudication based on the member's benefit plan, with many plans waiving the copay for preventive screening mammograms under ACA-compliant coverage requirements.

The period during which a member on a chronic maintenance medication has no medication available based on pharmacy dispensing claims, calculated as the gap between the exhaustion of one fill and the dispensing date of the next fill. Identifying members with medication adherence gaps enables health plans to implement targeted outreach interventions including pharmacy refill reminders, cost-sharing reduction programs, and care manager engagement to improve adherence before year-end PDC thresholds affect CMS Star Ratings.