Pill Splitting
Cutting prescription medications in half to double the number of days supply from one prescription. This practice, which decreases total cost of the drug therapy, is commonly used to manage the cost of cholesterol-reducing medications.

Preferred Brands
Brand-name drugs included on plan’s preferred drug list.

Preferred Drug List
List of drugs available to plan members with a lower copayment than drugs not on list.

Prescriber Profiling
Assessment of prescribing patterns to identify areas to manage utilization and cost of prescription drugs. Drug claim data is cut by prescriber (physician, physician assistant or nurse practitioner) to identify outliers in prescribing patterns.

Prescription Drug Plan (PDP)
U.S. Centers for Medicare & Medicaid Services-certified drug benefit program for the Medicare-eligible population.

Prilosec®
OTC proton pump inhibitor to treat gastro esophageal reflux disease (GERD) and related stomach disorders.

Prior Authorization
A process where the prescription claim is initially denied, but provides a mechanism for the claim to be covered via criteria established by the managed care organization (MCO) or the pharmacy benefit manager (PBM). This requires action from the physician, pharmacist, or patient to obtain coverage.

Quantity Limits
Limit on the number of pills or dosages allowable per claim.

Refill Too Soon Supply Limit
A system edit that rejects a drug claim if a refill is requested before a predefined number of days have passed since the initial fill date of prescription.

Retail Cost Share (30-day Supply)
Cost share amount for 30 days of a prescription therapy dispensed at a retail pharmacy. %: Cost sharing amount is a percentage of total prescription cost. $ Min: Minimum cost sharing amount. $ Max: Maximum cost sharing amount.

Retin A®
Brand-name dermatology drug commonly prescribed for cosmetic purposes.

Retiree Drug Subsidy
Amount of money the U.S. Centers for Medicare & Medicaid Services pays employers to subsidize employers’ funding of drug benefits for Medicare-eligible employees and retirees.

Retrospective DUR
Drug utilization review conducted after a prescription is adjudicated.

Single-source Brand
A drug product manufactured by one company or source.

Specialty Drugs (Biotech Drugs)
Drugs manufactured through biologic processes to treat chronic, complex or life-threatening conditions.

Specialty Pharmacy Benefit
Coverage of drugs manufactured through biologic processes to treat chronic, complex or life-threatening conditions.

Step Therapy
Treatment guidelines used to recommend drug therapy beginning with the least expensive therapy. More expensive therapies are only used when the patient fails to respond to the first-line drug.

Therapeutic Substitution
A pharmacist-initiated change in a dispensed drug when a medically equivalent drug is available for the prescription presented. State prescribing laws address the required physician permission for substitutions.

Wholesale Acquisition Cost (WAC)
The price used by a pharmaceutical manufacturer to sell prescription products to a wholesaler; also known as Wholesale List Price.

Wrap Around Coverage
Drug benefit coverage provided by employers to Medicare-eligible employees and retirees to supplement Medicare Part D coverage.

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