Pharmacy & insurance glossary
A glossary of common specialty pharmacy, insurance, and patient care terms.
A
Advance directive
A legal document that states a patient's wishes for medical treatment in the event they become unable to communicate their decisions themselves.
Adherence (medication adherence)
The degree to which a patient takes medication as prescribed, in the right dose, at the right time, and for the recommended duration.
Appeal (insurance appeal)
A formal request asking an insurance company to reconsider a denied claim or coverage decision, often supported by additional clinical information.
ACHC accreditation
A voluntary accreditation granted by the Accreditation Commission for Health Care, recognizing that a pharmacy meets nationally recognized standards for quality and patient safety.
B
Benefits investigation
The process of contacting a patient's insurance plan to confirm coverage, cost-sharing, and any requirements that apply before a medication is dispensed.
Biologic medication
A medication derived from living organisms, often used to treat complex chronic conditions and typically requiring special handling and storage.
Brand name drug
A medication marketed under a proprietary name by the company that originally developed and patented it.
C
Copay
A fixed amount a patient pays out of pocket for a covered prescription, with the remaining cost paid by their insurance plan.
Copay assistance program
A program, often sponsored by a drug manufacturer or nonprofit foundation, that helps eligible patients cover some or all of their out-of-pocket medication costs.
Coordination of benefits
The process of determining how two or more insurance plans will share responsibility for a patient's healthcare costs when more than one plan applies.
Controlled substance
A medication regulated by federal law due to its potential for misuse or dependence, subject to additional prescribing and dispensing rules.
Coverage determination
A decision made by a health plan about whether a specific medication or service will be covered under a patient's benefits.
D
Deductible
The amount a patient must pay out of pocket for covered services before their insurance plan begins to share the cost.
Delivery (medication delivery)
The service of shipping or hand-delivering prescriptions directly to a patient's home, often including any needed supplies.
Dispense as written (DAW)
An instruction from a prescriber indicating that a brand-name medication should be filled as prescribed rather than substituted with a generic equivalent.
E
Explanation of benefits (EOB)
A statement from an insurance company that details what services or medications were billed, what the plan paid, and what the patient may owe.
Effective date
The date on which an insurance policy or specific coverage benefit officially begins.
Eligibility verification
The process of confirming that a patient's insurance plan is active and that the plan covers the requested medication or service.
Electronic prescribing (e-prescribing)
The process of a prescriber sending a prescription directly to a pharmacy through a secure electronic system rather than a paper script.
Emergency refill
A short-term supply of medication dispensed to prevent a gap in therapy while a refill, authorization, or insurance issue is resolved.
Enrollment
The process of a patient signing up for pharmacy services, a manufacturer support program, or a specific insurance plan.
F
Formulary
A list of prescription medications covered by a specific insurance plan, often organized into cost tiers.
Financial assistance program
A program offered by a manufacturer, foundation, or pharmacy that helps qualifying patients afford the cost of their medication.
Fill (prescription fill)
The act of a pharmacy preparing and dispensing a prescribed medication to a patient.
Foundation copay assistance
Financial support provided by an independent nonprofit foundation to help patients with high medication costs, separate from manufacturer-sponsored programs.
Fraud, waste, and abuse (FWA)
A general term for improper billing or program practices that healthcare providers and pharmacies are required to guard against under federal and state regulations.
Full prescribing information
The complete labeling document approved for a medication, including its indications, dosing, warnings, and administration instructions.
G
Generic medication
A medication that contains the same active ingredient as a brand-name drug and is approved as therapeutically equivalent, typically at a lower cost.
Grievance
A formal complaint filed by a patient about the quality of care or service received, separate from an appeal of a coverage decision.
H
HIPAA
The Health Insurance Portability and Accountability Act, a federal law that protects the privacy and security of a patient's health information.
Home infusion therapy
The administration of medication through an IV or other infusion method in a patient's home rather than in a hospital or clinic.
I
Infusion suite
A dedicated clinical space where patients can receive infused medications on-site under the supervision of trained staff.
Insurance investigation
The process a pharmacy undertakes to determine a patient's coverage, benefit design, and any prior authorization requirements for a prescribed medication.
J
Jet injector
A needle-free device that uses high-pressure force to deliver injectable medication through the skin, sometimes used as an alternative to a standard syringe.
Joint Commission
An independent, nonprofit organization that accredits and certifies healthcare organizations across the United States based on quality and safety standards.
Journey (patient journey)
The full path a patient follows from diagnosis through treatment, including prescribing, insurance approval, dispensing, and ongoing care.
Justification (medical necessity)
Clinical documentation provided by a prescriber explaining why a specific medication or service is required for a patient's treatment.
K
Kit (injection supply kit)
A bundled set of supplies, such as syringes, alcohol swabs, and a sharps container, provided alongside an injectable medication to support home administration.
Key contact (care coordinator)
The designated pharmacy staff member who serves as a patient's main point of contact for questions about their therapy, refills, or insurance.
Knowledge base
A collection of guides, FAQs, and instructional resources that helps patients find answers about their medication and pharmacy services.
Kilogram-based dosing
A method of calculating medication doses based on a patient's body weight, commonly used for specialty and biologic therapies.
L
Limited distribution drug (LDD)
A specialty medication that a manufacturer has restricted to a select network of pharmacies due to its complexity, handling requirements, or monitoring needs.
Lot number
A unique identifier assigned to a batch of medication during manufacturing, used to track the product for quality and safety purposes.
License (pharmacy license)
The official authorization issued by a state board of pharmacy that permits a pharmacy to legally dispense medications.
Long-term therapy management
Ongoing pharmacist support for patients managing chronic conditions that require ongoing medication therapy over an extended period.
Live pharmacist support
Access to a licensed pharmacist by phone for questions about medications, side effects, or administration, available around the clock.
M
Medication therapy management (MTM)
A service in which a pharmacist reviews a patient's full medication regimen to identify potential interactions, improve adherence, and optimize outcomes.
Manufacturer copay card
A card or program offered by a drug manufacturer that reduces a patient's out-of-pocket cost for a specific brand-name medication.
Medication adherence
The extent to which a patient follows their prescribed medication schedule, including dose, timing, and duration.
Medicare Part D
The portion of Medicare that provides prescription drug coverage to eligible beneficiaries through private insurance plans.
Medicaid
A joint federal and state program that provides health coverage, including prescription benefits, to eligible low-income individuals and families.
Medication reconciliation
The process of creating an accurate, up-to-date list of all medications a patient is taking to prevent errors during transitions of care.
Manufacturer assistance program
A support program offered directly by a drug manufacturer to help eligible patients access their medication at reduced or no cost.
Mail-order pharmacy
A pharmacy service that ships prescription medications directly to a patient's home rather than requiring an in-person pickup.
N
Notice of Privacy Practices
A document required under HIPAA that explains how a healthcare provider or pharmacy may use and disclose a patient's protected health information.
Network (in-network pharmacy)
A pharmacy that has a contract with a patient's insurance plan to provide services at a negotiated, typically lower, cost.
National Provider Identifier (NPI)
A unique ten-digit identification number assigned to healthcare providers and organizations in the United States for billing and administrative purposes.
Needle disposal (sharps container)
A puncture-resistant container used to safely dispose of used needles and syringes after home injections.
O
On-site infusion suite
A dedicated space within a pharmacy or clinic where patients receive infused medications under professional supervision.
Out-of-pocket maximum
The most a patient will have to pay for covered healthcare services in a plan year before their insurance covers 100% of costs.
Order status
The current stage of a prescription, from insurance verification and fill to shipping or pickup readiness.
Open enrollment period
A designated time each year when individuals can enroll in or make changes to their health insurance plan.
Over-the-counter (OTC) medication
A medication that can be purchased without a prescription, as opposed to one that legally requires a prescriber's order.
P
Prior authorization
An approval required by some insurance plans before they will cover a specific medication, based on clinical information submitted by the prescriber.
Patient assistance program
A program, often run by a manufacturer or foundation, that provides free or discounted medication to patients who meet financial or insurance eligibility criteria.
Pharmacy benefit manager (PBM)
A company that manages prescription drug benefits on behalf of health insurers, negotiating formularies, pricing, and pharmacy networks.
Prescription refill
An additional supply of a previously dispensed medication provided under the same prescription, up to the number of refills authorized.
Privacy practices (Notice of)
The disclosure document that describes how a pharmacy uses and protects a patient's health information under HIPAA.
Point of care
The setting or moment at which a patient receives healthcare services, treatment, or medication administration.
Q
Quality assurance (pharmacy QA)
Ongoing processes a pharmacy follows to verify accuracy, safety, and compliance in every step of dispensing and patient care.
Quantity limit
A restriction set by an insurance plan on the amount of a medication that can be dispensed within a given time period.
Qualified health plan
A health insurance plan that meets certain standards and is certified to be sold on a health insurance marketplace.
R
Refill reminder
A notification sent to a patient ahead of time to help them request their next medication refill before their current supply runs out.
Reimbursement
The payment a pharmacy receives from an insurance plan or patient for a dispensed medication or service.
Referral
A recommendation from a prescriber or care provider directing a patient to a specialty pharmacy or other service for a specific need.
Rx number
The unique number assigned to a specific prescription, used to identify and track it throughout the filling and refill process.
Reconciliation (medication)
The process of comparing a patient's current medication list against new prescriptions to identify discrepancies or potential interactions.
Renewal (prescription renewal)
The process of obtaining a new prescription from a provider once the refills on a previous prescription have been exhausted.
Real-time benefit check
A tool that allows a pharmacy or prescriber to see a patient's specific medication cost and coverage details at the time a prescription is written.
Recall (drug recall)
An action taken by a manufacturer or regulator to remove a medication from the market due to a safety or quality concern.
Route of administration
The way a medication is taken into the body, such as by injection, infusion, orally, or topically.
Refrigerated storage (cold chain)
The temperature-controlled process used to store and ship medications that must remain refrigerated to stay safe and effective.
Reorder point
The point in a patient's medication supply, based on days remaining, at which a new refill should be requested to avoid a gap in therapy.
S
Specialty medication
A medication used to treat complex or chronic conditions that often requires special handling, administration, or monitoring.
Sharps container
A puncture-resistant container used for the safe disposal of used needles, syringes, and other sharp medical supplies.
Self-injection training
Instruction provided by a pharmacist or nurse that teaches a patient or caregiver how to safely administer an injectable medication at home.
Step therapy
An insurance requirement that a patient try one or more alternative medications before a specific medication will be covered.
Shipping & cold chain delivery
The process of packaging and shipping temperature-sensitive medications so they arrive safely within their required storage range.
T
Third-party payer
An entity, such as an insurance company or government program, that pays for healthcare services on behalf of a patient.
Titration
The gradual adjustment of a medication dose over time, under a prescriber's guidance, to reach the most effective and well-tolerated level.
Tier (formulary tier)
A cost category within an insurance plan's formulary that determines how much a patient pays out of pocket for a given medication.
Telepharmacy
The delivery of pharmacist consultation and services remotely through phone or video, expanding patient access to pharmacy care.
U
Utilization management
Insurance plan processes, such as prior authorization and step therapy, used to review and manage the appropriate use of medications.
Unit dose packaging
Medication packaged individually by single dose, often used to improve safety and accuracy in administration.
Urgent refill
A refill processed on an expedited basis to prevent a gap in a patient's therapy when time is a concern.
Uninsured/underinsured assistance
Support programs that help patients without adequate insurance coverage access and afford necessary medications.
V
Vial
A small glass or plastic container used to hold a liquid or powdered medication, commonly used for injectable therapies.
Verification of benefits
The process of confirming a patient's active insurance coverage and specific plan details before a medication is dispensed.
W
Welcome packet
A collection of materials given to new patients that introduces pharmacy services, policies, and key contact information.
Wholesaler (pharmaceutical wholesaler)
A licensed distributor that supplies medications from manufacturers to pharmacies.
Waste (medication waste disposal)
Proper procedures for safely disposing of unused or expired medication to protect patient safety and the environment.
X
Xerostomia
The medical term for dry mouth, a condition that can occur as a side effect of certain medications.
XR / extended-release formulation
A drug formulation designed to release medication gradually over time, often denoted by the letters XR, ER, or SR on a prescription label.
Y
Y-site compatibility
A connection point on an IV administration set where two solutions or medications can be combined during infusion, requiring compatibility verification.
Yearly benefit reset
The point each plan year when a patient's insurance deductible and out-of-pocket maximum reset, which can affect medication costs.
Young adult coverage
A provision under the Affordable Care Act that allows young adults to remain on a parent's health insurance plan until age 26.
Z
Zero balance due
An account status indicating that no outstanding payment is owed by the patient after insurance and any assistance programs have been applied.
Z-track injection technique
A method of intramuscular injection that helps seal medication into the muscle tissue to reduce leakage and skin irritation, often covered during home injection training.