Pharmacy

The lower limit or floor value for a pharmacy metric such as minimum dispensing quantity, minimum days supply, or minimum reimbursement threshold in a healthcare payment system. Used in PBM claims adjudication and pharmacy contract management to establish baseline payment floors.

Human-readable name of a pharmacy entity within clinical or PBM systems, such as a retail chain name or compounding pharmacy. Used by data engineers for display purposes, provider directory population, network reporting, and pharmacy reference data master management.

The group of retail, mail order, and specialty pharmacies contracted with a health plan or pharmacy benefit manager to dispense covered prescription drugs at negotiated rates, with members using in-network pharmacies receiving the in-network cost-sharing benefit. Pharmacy network composition affects member access, ingredient cost, dispensing fee rates, and overall pharmacy benefit cost, with preferred network designs offering lower cost-sharing for pharmacies meeting performance and pricing criteria.

The measurement of contracted pharmacy operational performance against defined service standards including generic dispensing rate, medication synchronization enrollment, MTM completion rate, patient counseling rates, and accuracy metrics, used by health plans and pharmacy benefit managers to assess pharmacy network quality and identify pharmacies for preferred network designation or performance improvement programs.

Reference number associated with a pharmacy transaction or entity within pharmacy and PBM systems, such as prescription number or pharmacy chain identifier. Used by data engineers for record linkage, transaction tracing, and cross-system reconciliation in claims pipelines.

Percentage value derived from pharmacy claims data, such as generic dispensing rate, formulary compliance rate, or member cost share percentage. Used by data engineers in PBM and claims analytics for performance reporting, contract compliance monitoring, and cost trend analysis.

A reference to the prior version of a pharmacy record in a healthcare data system. Used in pharmacy data management to track historical changes to pharmacy information including address updates, ownership changes, and network participation history over time.

Quality metrics assessing the safety, efficacy, and appropriateness of prescription drug use within a health plan population, including CMS Star Ratings medication adherence measures for diabetes, hypertension, and statins, HEDIS measures for antidepressant medication management, high-risk medication use in elderly populations, and concurrent opioid and benzodiazepine prescriptions. Pharmacy quality measures are among the highest-weighted components of CMS Star Ratings.

Measured quantity for pharmacy within Eligibility processes in Healthcare implementations. Used for reporting, integrations, and downstream analytics.

A reference value or benchmark used in pharmacy data systems for comparison or lookup purposes. Used in drug pricing, formulary management, and pharmacy network contracting to establish standard reference points for reimbursement calculations and performance benchmarking.

A sequential number assigned to identify the order or position of a pharmacy transaction or record within a batch or processing queue. Used in pharmacy claims processing, PBM adjudication, and EDI transaction sets to maintain record ordering and support batch reconciliation.

The difference between what a pharmacy benefit manager charges a health plan for a prescription drug and what the PBM actually pays the dispensing pharmacy, representing a revenue source for PBMs not disclosed in traditional fee-for-service PBM contracts. Spread pricing has been subject to significant regulatory scrutiny in Medicaid managed care with many states requiring PBMs to use pass-through pricing models that eliminate spread.

A coded value indicating the current operational or network status of a pharmacy in a healthcare data system. Common values include active, inactive, terminated, suspended, and pending. Used in pharmacy network management, claims adjudication, and provider directory accuracy reporting.

The precise date and time value recording when a pharmacy transaction or record event occurred including hours, minutes, and seconds. Used in pharmacy claims processing, dispensing records, and audit trails to capture exact event timing for HIPAA compliance and pharmacy operations analytics.

The aggregate sum of pharmacy metrics such as total prescription count, total drug cost, total dispensing fees, or total reimbursement amount across a defined time period or population. Used in pharmacy financial reporting, PBM analytics, and drug utilization trend analysis.

A temporary supply of a non-formulary or restricted medication dispensed to a new health plan member during a transition period after enrollment to allow time for prior authorization review, prescriber consultation, or therapeutic alternative identification without disrupting ongoing treatment. CMS requires Medicare Part D plans to provide transition fills for non-formulary drugs during the first 90 days of enrollment with at least a 30-day supply at standard cost-sharing.

A coded classification identifying the type of pharmacy such as retail, mail-order, specialty, long-term care, hospital outpatient, or compounding pharmacy. Used in NCPDP pharmacy directory records, network adequacy analysis, and pharmacy claims data to categorize dispensing locations.

The fixed dollar amount a member is required to pay out-of-pocket at the time of a physical examination service. This cost-sharing value is defined by the member's health plan benefit design and applied during medical claims adjudication for preventive or routine physical visits.

The fixed out-of-pocket dollar amount a member must pay for covered services as defined by their specific health plan benefit structure. This cost-sharing value is applied during claims adjudication and varies by plan tier, service type, and benefit year configuration.

A drug rebate applied at the pharmacy counter at the time of dispensing to reduce the member out-of-pocket cost for a prescription drug, distinct from rebates paid directly to health plans after the fact. CMS requires Medicare Part D plans to apply negotiated rebates at the point of sale for insulin and other high-cost drugs under the Inflation Reduction Act, directly reducing member cost-sharing at the pharmacy.