Table 2.

Glossary of Terms

Term	Definition
Formulary	List of covered medications
Pharmacy Benefit Manager (PBM)	A third party used by an insurance company to negotiate with manufacturers and often review prior authorizations for medications and other medication use activities
Deductible	Amount of money a person must spend before certain healthcare benefits start
Co-payment	The amount of money a person pays after their insurance benefit has been applied
Co-insurance	Typically a % owed by a patient for a particular good or service (as opposed to a set fee)
Prior authorization (PA)	Process that requires providers to submit information before payors will provide coverage of a product or service
Step edit/step therapy	Treatment(s) tried and failed prior to another treatment being approved
Quantity limit	Amount of drug/ time permitted Example: 1 syringe per 56 days
Site of Care optimization	Re-direction of services to a (typically) lower-cost setting (to payor, not necessarily the patient)
Appeal	Formal process of requesting reconsideration of a decision made by the payor
Peer to Peer	Provider to provider discussion (typically a phone call) that may or may not be part of the appeals process whereby the prescribing provider discusses rationale for use of a medication to a provider employed by the insurance company
Independent Medical Review or External Review	Process required by law that allows for review of a request outside of the payor. Typically occurs after internal appeals are exhausted. Completed by the state or an independent contracted company
Bridge Program	Manufacturer related term. This is a temporary, free supply of medication provided to a patient with commercial insurance when they are awaiting payor approval or have a gap in medication access. Programs may go by various names.
Co-pay savings programs	Offered by manufacturers and independent groups (e.g. Patient Assistance Fund, Patient Access Network (PAN) Foundation, etc.). Free programs for those with non-government insurance to assist with copay costs. Medication must be covered by insurance and then copay card can apply. Typically has an annual limit.
Patient assistance programs	Offered by manufacturers and independent groups (e.g. Patient Assistance Fund, Patient Access Network (PAN) Foundation). Includes government and non-government insurance and uninsured. Medication is provided free to the person. Typically has financial qualifications required
Copay accumulator	Program that payors use to limit how manufacturer contributions count towards deductibles and out of pocket spending. Manufacturer coupon is used until funds run out and then patient begins to spend toward deductible and out of pocket
Copay maximizer	Program that payors use to limit how manufacturer contributions count towards deductibles and out of pocket spending. The value of the manufacturer coupon is spread evenly across the year
Buy and bill	Process where medication is purchased by the same provider that administers the medication and then bills insurance for the medication and administration costs
Brown bagging	Process by which a medication is shipped from a pharmacy to a patient directly and the patient then brings the medication to a provider office or infusion center for administration or the medication is administered in their home
White bagging	Process by which a medication is shipped from a pharmacy directly to a provider office or infusion center for patient administration