Policies & Guidelines
- Compliance
- Definitions
- Ambulatory Surgical Services
- Billing Policy
- Children's Services
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- Long-Term Care
- Mental Health Services
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- Pharmacy Services
- Physician and Professional Services
- Rehabilitative Services
- Requirements for Providers
- Service Authorization
- Substance Use Disorder Services
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- Tribal and Indian Health Services
- Legal References
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- Ambulatory Surgical Services
- Billing Policy
- CFSS
- Children's Services
- Chiropractic Services
- Clinic Services
- Dental
- Equipment and Supplies
- HCBS Elderly Waiver
- Home Care
- Hospice
- Hospital Services
- Housing Stabilization Services
- Immunizations and Vaccinations
- Inpatient Hospital Notification and Authorization
- Laboratory/Pathology, Radiology and Diagnostic Services
- Long-Term Care
- Member Eligibility
- Mental Health Services
- Optical Services
- Pharmacy Services
- Physician and Professional Services
- Recuperative Care
- Rehabilitative Services
- Requirements for Providers
- Service Authorization
- Substance Use Disorder Services
- Transportation
- Tribal and Indian Health Services
- Quality: HEDIS
- Policies & Procedures
Pharmacy Services
Definitions
Agreement: The Pharmacy Agreement between the pharmacy and MedImpact.
Ancillary Charge: A charge in addition to the copay that the member is required to pay to a pharmacy for prescription drug services. The ancillary charge is assessed when the prescribing provider or member has requested a drug that is not on the Drug Formulary or the Maximum Allowable Cost (MAC) list.
Average Wholesale Price (AWP): The AWP of a prescription drug service at the time a claim is processed as established in the MedImpact price file and updated no less than weekly by First Databank or by such other national drug database as MedImpact may solely designate.
Benefit Plan: Any health care plan, program, group, or individual plan policy, agreement, or other arrangement sponsored, issued, or administered by a benefit sponsor, which includes outpatient pharmaceutical services or benefits, or access to pricing under a Pharmacy Provider Agreement in accordance with the terms of the benefit plan, including, but not limited to, plans approved by the Centers for Medicare & Medicaid Services (CMS) under the Medicare Part D Program.
Compound Prescription: A prescription where two or more medications are mixed together. One of these drugs must be a Federal legend drug. The end product must not be available in an equivalent commercial form. A prescription will not be considered a compound prescription if it is reconstituted or if only water, alcohol, or sodium chloride solutions are added to the active ingredient.
Copay: The amount a member is required to pay under the benefit plan for the prescription drug service, and shall include applicable deductibles, co-insurance, payments made by a subscriber for covered drugs under the Medicare Part D program after exhausting the Medicare Part D initial coverage limit, or ancillary charges.
Drug Formulary: A document or documents listing various pharmaceutical products that are provided to pharmacies, members, physicians, or other health care providers for the purpose of guiding the prescribing and dispensing of pharmaceutical products. The Drug Formulary may be amended from time to time by MedImpact or a benefit sponsor. Also referred to as the “Drug List.”
Federal Legend Drug: A drug that is required by law to bear on its packaging, “Caution: Federal law prohibits dispensing without a prescription” or “Rx Only.”
Maximum Allowable Cost (MAC): The list delineating the maximum per unit reimbursement as established and solely determined by MedImpact for a multiple source prescription drug, medical product, or device at the time a claim is processed. The MAC is subject to review and modification by MedImpact in its sole discretion.
Medicare Part D Program: The program created by Congress in the Medicare Modernization Act of 2003 that created the Medicare Part D prescription drug benefit program under Part D of Title XVIII of the Social Security Act.
Member: A person who is properly enrolled in or covered by a benefit plan and entitled to obtain a prescription drug service at the time a prescription is dispensed. This includes a subscriber under the Medicare Part D program.
Payer: The entity that is financially responsible for payment of a prescription drug service. A benefit sponsor or member or both may be the payer.
Pharmacy: An established place of business, licensed by a state board of pharmacy, in which prescriptions, drugs, medicines, chemicals, and poisons are prepared, compounded, dispensed, vended, or sold to or for the use of patients and from which related clinical pharmacy services are delivered.
Pharmacy Payment: The amount payable to the pharmacy under the terms of the Agreement.
Pharmacy Service: The dispensing of drugs, counseling, concurrent drug utilization review (DUR) and other activities as described in MN Stat. sec. 151.01, subd. 27, or as performed by a dispensing physician.
Plan Sponsor: An entity that sponsors, issues, or administers a benefit plan and has agreed with MedImpact to use a MedImpact-administered network to process and adjudicate the prescription drug service.
Point of Sale (POS): The method of submitting claims online through an automated claim adjudication process, which includes interactive communications between a terminal located at a pharmacy and a claims processor designated by MedImpact.
Prescribing Provider: A doctor of medicine (MD) or other health care professional who is duly licensed and qualified under the laws of the jurisdiction in which prescription drug services are received and may, in the usual course of his/her practice, legally prescribe prescription drug services for members.
Prescription Drug Service: An outpatient drug product, item, or service that is covered under a member’s benefit plan and is provided to a member pursuant to a prescription issued by a prescribing provider in accordance with the Pharmacy Agreement.
Signature Logs: The pharmacy shall maintain a signature log, or other evidence specifically approved by MedImpact, at each pharmacy location for each prescription drug service dispensed to a member, which acknowledges receipt of the prescription drug service. Each member (or his/her authorized agent) who receives a prescription drug service shall be required to sign the log, acknowledging the date the prescription drug service was received, and the prescription number. Electronic prescriptions must have provisions for documenting receipt of the prescription authorized by both pharmacy and patient.
Usual and Customary (U&C) Charge: The lowest price the pharmacy would charge to a particular customer if such customer were paying cash for the identical prescription drug services on the date dispensed. This includes any applicable discounts including, but not limited to, senior discounts, frequent shopper discounts, and other special discounts offered to attract customers. A pharmacy cannot have a U&C charge for prescription drug programs that differs from either cash customers or other third-party programs. The pharmacy must submit the accurate U&C charge with respect to all claims for prescription drug services.
Wholesale Acquisition Cost: The wholesale acquisition cost of a prescription drug service at the time a claim is processed as established in the MedImpact price file and updated no less than twice monthly by Medi-Span or by such other national drug database as MedImpact may solely designate.
PW_03-19_143
Updated_03/14/2019
