Prior Authorization (PA) – Obtaining approval for a particular service or medication before it is provided.
Drug List – A comprehensive list of clinically efficacious and cost-effective drug products, identified and selected by a group of knowledgeable and duly licensed clinicians, to be utilized by the Plan in order to deliver a high quality of care to members while containing costs.
Pharmacy Benefits Manager (PBM) – An entity contracted with PHP to provide pharmacy services (including performing prior authorization evaluations).
AB-Rated Generic – A pharmaceutical product rated in the Federal Food and Drug administration Orange Book as being equivalent to the innovator brand product.
Generic Substitution – Dispensing a generic drug in place of a brand-name medication.
Generic Drug – Chemically equivalent copy designed from a brand-name drug whose patent has expired.
Non-Equivalent Drug Product Formulary – A list of drug(s) for which generic substitution is not required.
Therapeutic Interchange – The dispensing of a drug product different from that which is prescribed, but which is deemed to be therapeutically equivalent to the original product prescribed.
Step-Therapy Protocol – A step-by-step set of directions that identifies the progression of drug therapy from first line therapy to the most aggressive drug therapy.
Brand Drug – A drug sold by a drug company under a specific name or trademark and that is protected by a patent. Brand name drugs may be available by prescription or over the counter.
Plan Preferred Brand – Branded drugs that are preferred over the generic formulation.