Pharmacy

A medication adherence metric calculating the ratio of the sum of days supply of all fills to the number of days in the measurement period, which can exceed 100% when multiple overlapping fills are dispensed. MPR differs from proportion of days covered in that it can be greater than 1.0 and uses a different denominator calculation. MPR is used in some pharmacy adherence programs but PDC has become the preferred metric for CMS Star Ratings and HEDIS measures.

A pharmacy program aligning the refill dates of all of a patient chronic medications to a single monthly pickup date, improving medication adherence by simplifying the refill process, enabling pharmacist counseling at monthly appointments, and reducing the number of pharmacy visits required. Medication synchronization enrollment rates are tracked as a pharmacy network performance metric and are associated with improved adherence measured by proportion of days covered.

A service provided by pharmacists to optimize therapeutic outcomes for individual patients with complex drug regimens or multiple chronic conditions, including comprehensive medication review, targeted medication review, personal medication record maintenance, and medication action plan development. MTM services are required for Medicare Part D plans for eligible beneficiaries and MTM completion rates are tracked as a CMS Star Ratings measure.

The fixed out-of-pocket dollar amount tied to a specific performance or utilization metric used within a value-based or incentive-driven health plan benefit design. Applied during claims adjudication to enforce cost-sharing rules aligned with quantitative thresholds such as quality scores, utilization rates, or care compliance measurements.

The fixed dollar amount a member pays out-of-pocket for healthcare services related to disease burden or chronic condition management. Used in claims adjudication to track patient cost-sharing obligations tied to morbidity-coded encounters and risk adjustment reporting.

The fixed dollar amount a member is responsible for paying on claims associated with end-of-life or terminal condition services. Used in claims processing to capture patient cost-sharing on encounters classified under mortality-related diagnosis codes for actuarial and financial reporting.

The fixed out-of-pocket dollar amount a member owes at the time of service for a Magnetic Resonance Imaging procedure. Applied during claims adjudication based on the member's benefit plan design, determining patient responsibility for MRI diagnostic imaging services.

A weekly-updated drug pricing benchmark published by CMS reflecting the average price paid by retail community pharmacies to acquire prescription drug products, calculated from a monthly survey of pharmacy invoice data. NADAC is used by state Medicaid programs as the basis for ingredient cost reimbursement to better reflect actual acquisition costs compared to AWP-based benchmarks. NADAC data is publicly available from CMS.

The unique account identifier associated with a National Drug Code in pharmacy billing and drug dispensing systems. Used to link NDC-level drug transactions to a specific payer, pharmacy, or billing account for reconciliation, claims processing, and pharmacy benefit management reporting.

A binary flag indicating whether a specific National Drug Code is currently active and eligible for dispensing, billing, or formulary inclusion. Used in pharmacy benefit management systems to filter valid NDCs during claims adjudication, drug pricing lookups, and formulary administration.

The current lifecycle state of a National Drug Code, indicating whether the drug product is active, discontinued, or inactive within drug reference databases such as FDA NDC Directory. Used in pharmacy systems to validate NDC eligibility during prescription processing and claims adjudication.

The physical or mailing address associated with the labeler segment of a National Drug Code, typically referencing the drug manufacturer or repackager registered with the FDA. Used in pharmacy data management to verify labeler identity and support drug supply chain compliance reporting.

The dollar value applied to modify the original billed or allowed amount on a pharmacy claim for a specific National Drug Code. Adjustments may reflect pricing corrections, rebate recalculations, or coordination of benefits changes processed during pharmacy claims adjudication or post-adjudication reconciliation.

The elapsed time in years since a National Drug Code was first assigned or approved by the FDA. Used in drug reference and formulary management systems to assess product maturity, patent lifecycle stage, and eligibility transitions between branded and generic drug classifications.

The maximum dollar amount a payer will reimburse for a drug product identified by its National Drug Code, based on contracted rates or drug pricing benchmarks such as AWP or MAC pricing. Used in pharmacy claims adjudication to calculate plan liability and member cost-sharing obligations.

The total monetary value associated with a pharmacy transaction for a specific National Drug Code, representing either the billed, allowed, or paid amount depending on context. Used in pharmacy claims processing and drug spend analytics to track financial exposure at the NDC level.

The regulatory or formulary authorization state of a National Drug Code, indicating whether the drug has received FDA marketing approval and payer formulary acceptance. Used in pharmacy benefit management to determine dispensing eligibility, prior authorization requirements, and step therapy compliance.

The identifier of the individual, system, or regulatory body that authorized a National Drug Code for formulary inclusion, prior authorization, or dispensing. Used in pharmacy benefit management workflows to maintain audit trails for drug approval decisions and formulary exception processing.

The timestamp recording when a drug product associated with a specific National Drug Code arrived at a dispensing location such as a pharmacy or healthcare facility. Used in pharmacy inventory management and drug supply chain tracking to monitor delivery timeliness and stock replenishment cycles.

The calendar date on which a drug product identified by its National Drug Code was received at a dispensing pharmacy or healthcare facility. Used in pharmacy inventory and supply chain management systems to track shipment receipt, expiration dating, and drug availability for dispensing.