Day1 ======= PBM: Pharmacy benefit managers: is a third party administator providing services for the members enrolled

for prescription drugs. who is our client? tiger : CVS CAREMARK CVS: REtail Pharmacy CAREMARK: PBM RETAIL PHARMACY: Who are the Major retail pharmacy CVS,Walgreen, Walmart Major PBM in US: caremark, medco, aetna Major health insurance comapanies: Aetna, Cigna, BCBS, AHIC ...etc Insurance: Sharing of risk with others Types of Insurance: 1. Life 2. General(Health Insurance) 3. Reinsuarnce (Insurance of the insurer): GIC: In insurance, there r 2 terminologies: 1. Insured (Member) 2. Insurer (Insurnace company) mode of providing insuarnce: 1 . Group health plan 2. Individual health plan

what is the differnce between copay and patient pay? Patient pay= deductible+copay+tax(vat) Types of copay? 1. fixed dollar copay 2. % copay(coinsurance) 3. mixed of above two Health Insurance Plans: 1. Traditional Indemnity features of traditional indemnity: 1. NO PCP concept 2. Freedom of choice Day2: ======= 2. MC Plan is divided into 3 types a. HMO (Health maintaince/management Org) b. PPO (Preffered providers Org) c. POS (Point of Service)HMO+additional service a member can chhose at the time of service

HMO: PCP: primary care physician is the gate keeper for this service is divided into OPEN and CLOSED 1. Gathering Demographic data and eligibility details of the customers 2. Calculating the risk exposure (Actuaries) 3. creation of product (Senior marketing managers & admin) 4. Marketing the product 5. Enrolling under some health plan 6. At the time of taking the service, Patient came to provider, taking the servi ce and paying the patient pay to the provider and came back 7. Submitter submits the claim 8. Claim gets Processed 9. Amount receiveable and payable 10.EOB (explanation of benefit) what are the types of claim w.r.t Pharmacy? 1 . retail claim :pharmacy 2 . paper/manual claim:member 3 . Mail order claim:online 4 . Batch claim:when a new client comes for a PBM, all the history data should b loaded in to the adjudication engine of that PBM. at a time loading is called batch claim. who are the clients of PBM? Ans : sponsorer-organisation, MCO, Fed & state mandates , sometimes insurance co mp Client hierarchy: 1 Carrier (Insurance comp)----many accounts (Organisations)-------1 account---many Groups 1 group----many members MCO: managed care Organisation:HMO,PPO,POS Q: what is the difference between underwriting & Clearing house? Day3 ======= NCPDP , HIPAA under fed & state mandates Title I: Health Care Access, Portability, and Renewability: Title I of HIPAA regulates the availability and breadth of group health plans an d certain individual health insurance policies. It amended the Employee Retireme nt Income Security Act, the Public Health Service Act, Title I also limits restrictions that a group health plan can place on benefits for preexisting conditions. Group health plans may refuse to provide benefits re lating to preexisting conditions for a period of 12 months after enrollment in t he plan or 18 months in the case of late enrollment.[1] However, individuals may reduce this exclusion period if they had group health plan coverage or health i nsurance prior to enrolling in the plan. Title I allows individuals to reduce th

e exclusion period by the amount of time that they had "creditable coverage" pri or to enrolling in the plan and after any "significant breaks" in coverage.[2] " Creditable coverage" is defined quite broadly and includes nearly all group and individual health plans, Medicare, and Medicaid.[3] A "significant break" in cov erage is defined as any 63 day period without any creditable coverage.[4] Title II: Preventing Health Care Fraud and Abuse; Administrative Simplification; Medical Liability Reform These rules apply to "covered entities" as defined by HIPAA and the HHS. Covered entities include health plans, health care clearinghouses, such as billing serv ices and community health information systems, and health care providers that tr ansmit health care data in a way that is regulated by HIPAA.[8][9] Per the requirements of Title II, the HHS has promulgated five rules regarding A dministrative Simplification: the Privacy Rule, the Transactions and Code Sets R ule, the Security Rule, the Unique Identifiers Rule, and the Enforcement Rule. [edit] Privacy Rule A covered entity may disclose PHI to facilitate treatment, payment, or health ca re operations,[14] or if the covered entity has obtained authorization from the individual.[15] However, when a covered entity discloses any PHI, it must make a reasonable effort to disclose only the minimum necessary information required t o achieve its purpose.[16] The Privacy Rule gives individuals the right to request that a covered entity co rrect any inaccurate PHI.[17] It also requires covered entities to take reasonab le steps to ensure the confidentiality of communications with individuals.[18] F or example, an individual can ask to be called at his or her work number, instea d of home or cell phone number. The Privacy Rule requires covered entities to notify individuals of uses of thei r PHI. Covered entities must also keep track of disclosures of PHI and document privacy policies and procedures.[19] They must appoint a Privacy Official and a contact person[20] responsible for receiving complaints and train all members of their workforce in procedures regarding PHI.[21] An individual who believes that the Privacy Rule is not being upheld can file a complaint with the Department of Health and Human Services Office for Civil Righ ts (OCR).[22][23] However, according to the Wall Street Journal, the OCR has a l ong backlog and ignores most complaints. "Complaints of privacy violations have been piling up at the Department of Health and Human Services. Between April 200 3 and Nov. 30, the agency fielded 23,896 complaints related to medical-privacy r ules, but it has not yet taken any enforcement actions against hospitals, doctor s, insurers or anyone else for rule violations. A spokesman for the agency says it has closed three-quarters of the complaints, typically because it found no vi olation or after it provided informal guidance to the parties involved."[24] [edit] Transactions and Code Sets Rule The HIPAA/EDI provision was scheduled to take effect from October 16, 2003 with a one-year extension for certain "small plans". However, due to widespread confu sion and difficulty in implementing the rule, CMS granted a one-year extension t o all parties.[citation needed] On January 1, 2012 the newest version 5010 becom es effective, replacing the version 4010.[25] This allows for the larger field s ize of ICD-10-CM as well as other improvements. After July 1, 2005 most medical providers that file electronically did have to f ile their electronic claims using the HIPAA standards in order to be paid.[citat ion needed] Key EDI(X12) transactions used for HIPAA compliance are: EDI Health Care Claim Transaction set (837) is used to submit health care claim billing information, encounter information, or both, except for retail pharmacy claims (see EDI Retail Pharmacy Claim Transaction). It can be sent from provider s of health care services to payers, either directly or via intermediary billers

and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/o r payment of health care services within a specific health care/insurance indust ry segment. For example, a state mental health agency may mandate all healthcare claims, Pro viders and health plans who trade professional (medical) health care claims elec tronically must use the 837 Health Care Claim: Professional standard to send in claims. As there are many different business applications for the Health Care cl aim, there can be slight derivations to cover off claims involving unique claims such as for Institutions, Professionals, Chiropractors, and Dentists etc. EDI Retail Pharmacy Claim Transaction (NCPDP Telecommunications Standard version 5.1) is used to submit retail pharmacy claims to payers by health care professi onals who dispense medications, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit claims for retail pharmac y services and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers a nd regulatory agencies to monitor the rendering, billing, and/or payment of reta il pharmacy services within the pharmacy health care/insurance industry segment. EDI Health Care Claim Payment/Advice Transaction Set (835) can be used to make a payment, send an Explanation of Benefits (EOB), send an Explanation of Payments (EOP) remittance advice, or make a payment and send an EOP remittance advice on ly from a health insurer to a health care provider either directly or via a fina ncial institution. EDI Benefit Enrollment and Maintenance Set (834) can be used by employers, union s, government agencies, associations or insurance agencies to enroll members to a payer. The payer is a healthcare organization that pays claims, administers in surance or benefit or product. Examples of payers include an insurance company, health care professional (HMO), preferred provider organization (PPO), governmen t agency (Medicaid, Medicare etc.) or any organization that may be contracted by one of these former groups. EDI Payroll Deducted and other group Premium Payment for Insurance Products (820 ) is a transaction set which can be used to make a premium payment for insurance products. It can be used to order a financial institution to make a payment to a payee. EDI Health Care Eligibility/Benefit Inquiry (270) is used to inquire about the h ealth care benefits and eligibility associated with a subscriber or dependent. EDI Health Care Eligibility/Benefit Response (271) is used to respond to a reque st inquire about the health care benefits and eligibility associated with a subs criber or dependent. EDI Health Care Claim Status Request (276) This transaction set can be used by a provider, recipient of health care products or services or their authorized age nt to request the status of a health care claim. EDI Health Care Claim Status Notification (277) This transaction set can be used by a health care payer or authorized agent to notify a provider, recipient or a uthorized agent regarding the status of a health care claim or encounter, or to request additional information from the provider regarding a health care claim o r encounter. This transaction set is not intended to replace the Health Care Cla im Payment/Advice Transaction Set (835) and therefore, is not used for account p ayment posting. The notification is at a summary or service line detail level. T he notification may be solicited or unsolicited. EDI Health Care Service Review Information (278) This transaction set can be use d to transmit health care service information, such as subscriber, patient, demo graphic, diagnosis or treatment data for the purpose of request for review, cert ification, notification or reporting the outcome of a health care services revie w. EDI Functional Acknowledgement Transaction Set (997) this transaction set can be used to define the control structures for a set of acknowledgments to indicate the results of the syntactical analysis of the electronically encoded documents.

Although it is not specifically named in the HIPAA Legislation or Final Rule, i t is necessary for X12 transaction set processing . The encoded documents are th e transaction sets, which are grouped in functional groups, used in defining tra nsactions for business data interchange. This standard does not cover the semant ic meaning of the information encoded in the transaction sets. [edit] Security Rule The Final Rule on Security Standards was issued on February 20, 2003. It took ef fect on April 21, 2003 with a compliance date of April 21, 2005 for most covered entities and April 21, 2006 for "small plans". The Security Rule complements th e Privacy Rule. While the Privacy Rule pertains to all Protected Health Informat ion (PHI) including paper and electronic, the Security Rule deals specifically w ith Electronic Protected Health Information (EPHI). It lays out three types of s ecurity safeguards required for compliance: administrative, physical, and techni cal. For each of these types, the Rule identifies various security standards, an d for each standard, it names both required and addressable implementation speci fications. Required specifications must be adopted and administered as dictated by the Rule. Addressable specifications are more flexible. Individual covered en tities can evaluate their own situation and determine the best way to implement addressable specifications. Some privacy advocates have argued that this "flexib ility" may provide too much latitude to covered entities. [26] The standards and specifications are as follows: Administrative Safeguards policies and procedure s designed to clearly show how the entity will comply with the act o Covered entities (entities that must comply with HIPAA requirements) must adop t a written set of privacy procedures and designate a privacy officer to be resp onsible for developing and implementing all required policies and procedures. o The policies and procedures must reference management oversight and organizati onal buy-in to compliance with the documented security controls. o Procedures should clearly identify employees or classes of employees who will have access to electronic protected health information (EPHI). Access to EPHI must be restricted to only those employees who have a need for it to complete th eir job function. o The procedures must address access authorization, establishment, modification, and termination. o Entities must show that an appropriate ongoing training program regarding the handling of PHI is provided to employees performing health plan administrative f unctions. o Covered entities that out-source some of their business processes to a third p arty must ensure that their vendors also have a framework in place to comply wit h HIPAA requirements. Companies typically gain this assurance through clauses in the contracts stating that the vendor will meet the same data protection requir ements that apply to the covered entity. Care must be taken to determine if the vendor further out-sources any data handling functions to other vendors and moni tor whether appropriate contracts and controls are in place. o A contingency plan should be in place for responding to emergencies. Covered e ntities are responsible for backing up their data and having disaster recovery p rocedures in place. The plan should document data priority and failure analysis, testing activities, and change control procedures. o Internal audits play a key role in HIPAA compliance by reviewing operations wi th the goal of identifying potential security violations. Policies and procedure s should specifically document the scope, frequency, and procedures of audits. A udits should be both routine and event-based. o Procedures should document instructions for addressing and responding to secur ity breaches that are identified either during the audit or the normal course of operations. Physical Safeguards controlling physical access to protect against inappropriate access to protected data o Controls must govern the introduction and removal of hardware and software fro m the network. (When equipment is retired it must be disposed of properly to ens ure that PHI is not compromised.) o Access to equipment containing health information should be carefully controll ed and monitored.

o Access to hardware and software must be limited to properly authorized individ uals. o Required access controls consist of facility security plans, maintenance recor ds, and visitor sign-in and escorts. o Policies are required to address proper workstation use. Workstations should b e removed from high traffic areas and monitor screens should not be in direct vi ew of the public. o If the covered entities utilize contractors or agents, they too must be fully trained on their physical access responsibilities. Technical Safeguards controll ing access to computer systems and enabling covered entities to protect communic ations containing PHI transmitted electronically over open networks from being i ntercepted by anyone other than the intended recipient. o Information systems housing PHI must be protected from intrusion. When informa tion flows over open networks, some form of encryption must be utilized. If clos ed systems/networks are utilized, existing access controls are considered suffic ient and encryption is optional. o Each covered entity is responsible for ensuring that the data within its syste ms has not been changed or erased in an unauthorized manner. o Data corroboration, including the use of check sum, double-keying, message aut hentication, and digital signature may be used to ensure data integrity. o Covered entities must also authenticate entities with which they communicate. Authentication consists of corroborating that an entity is who it claims to be. Examples of corroboration include: password systems, two or three-way handshakes , telephone callback, and token systems. o Covered entities must make documentation of their HIPAA practices available to the government to determine compliance. o In addition to policies and procedures and access records, information technol ogy documentation should also include a written record of all configuration sett ings on the components of the network because these components are complex, conf igurable, and always changing. o Documented risk analysis and risk management programs are required. Covered en tities must carefully consider the risks of their operations as they implement s ystems to comply with the act. (The requirement of risk analysis and risk manage ment implies that the act s security requirements are a minimum standard and place s responsibility on covered entities to take all reasonable precautions necessar y to prevent PHI from being used for non-health purposes.) [edit] Unique Identifiers Rule (National Provider Identifier) HIPAA covered entities such as providers completing electronic transactions, hea lthcare clearinghouses, and large health plans, must use only the National Provi der Identifier (NPI) to identify covered healthcare providers in standard transa ctions by May 23, 2007. Small health plans must use only the NPI by May 23, 2008 . Effective from May 2006 (May 2007 for small health plans), all covered entities using electronic communications (e.g., physicians, hospitals, health insurance c ompanies, and so forth) must use a single new NPI. The NPI replaces all other id entifiers used by health plans, Medicare (i.e., the UPIN), Medicaid, and other g overnment programs. However, the NPI does not replace a provider's DEA number, s tate license number, or tax identification number. The NPI is 10 digits (may be alphanumeric), with the last digit being a checksum. The NPI cannot contain any embedded intelligence; in other words, the NPI is simply a number that does not itself have any additional meaning. The NPI is unique and national, never re-use d, and except for institutions, a provider usually can have only one. An institu tion may obtain multiple NPIs for different "subparts" such as a free-standing c ancer center or rehab facility. [edit] Enforcement Rule On February 16, 2006, HHS issued the Final Rule regarding HIPAA enforcement. It became effective on March 16, 2006. The Enforcement Rule sets civil money penalt ies for violating HIPAA rules and establishes procedures for investigations and hearings for HIPAA violations; however, its deterrent effects seem to be negligi ble with few prosecutions for violations.[27] Wikisource has original text relat

ed to this article: American Recovery and Reinvestment Act of 2009/Division A/Ti tle XIII/Subtitle D [edit] HITECH Act: Privacy Requirements Subtitle D of the Health Information Technology for Economic and Clinical Health Act (HITECH Act), enacted as part of the American Recovery and Reinvestment Act of 2009, and addresses the privacy and security concerns associated with the el ectronic transmission of health information. This subtitle extends the complete Privacy and Security Provisions of HIPAA to b usiness associates of covered entities. This includes the extension of newly upd ated civil and criminal penalties to business associates. These changes are also required to be included in any business associate agreements with covered entit ies. On November 30, 2009, the regulations associated with the new enhancements to HIPAA enforcement took effect.[28] Another significant change brought about in Subtitle D of the HITECH Act, is the new breach notification requirements. This imposes new notification requirement s on covered entities, business associates, vendors of personal health records ( PHR) and related entities if a breach of unsecured protected health information (PHI) occurs. On April 27, 2009, the Department of Health and Human Services (HH S) issued guidance on how to secure protected health information appropriately.[ 29] Both HHS and the Federal Trade Commission (FTC) were required under the HITE CH Act to issue regulations associated with the new breach notification requirem ents. The HHS rule was published in the Federal Register on August 24, 2009,[30] and the FTC rule was published on August 25, 2009.[31] The final significant change made in Subtitle D of the HITECH Act, implements ne w rules for the accounting of disclosures of a patient's health information. It extends the current accounting for disclosure requirements to information that i s used to carry out treatment, payment and health care operations when an organi zation is using an electronic health record (EHR). This new requirement also lim its the timeframe for the accounting to three years instead of six as it current ly stands. These changes won't take effect until January 1, 2011, for organizati ons implementing EHRs between January 1, 2009 and January 1, 2011, and January 1 , 2013, for organizations who had implemented an EHR prior to January 1, 2009. [edit] Effects on research and clinical care The enactment of the Privacy and Security Rules has caused major changes in the way physicians and medical centers operate. The complex legalities and potential ly stiff penalties associated with HIPAA, as well as the increase in paperwork and the cost of its implementation, were causes for concern among physicians and medical centers. An August 2006 article in the journal Annals of Internal Medicine detailed some su ch concerns over the implementation and effects of HIPAA.[32] [edit] Effects on research HIPAA restrictions on researchers have affected their ability to perform retrosp ective, chart-based research as well as their ability to prospectively evaluate patients by contacting them for follow-up. A study from the University of Michig an demonstrated that implementation of the HIPAA Privacy rule resulted in a drop from 96% to 34% in the proportion of follow-up surveys completed by study patie nts being followed after a heart attack.[33] Another study, detailing the effect s of HIPAA on recruitment for a study on cancer prevention, demonstrated that HI PAA-mandated changes led to a 73% decrease in patient accrual, a tripling of tim e spent recruiting patients, and a tripling of mean recruitment costs.[34] In addition, informed consent forms for research studies now are required to inc lude extensive detail on how the participant's protected health information will be kept private. While such information is important, the addition of a lengthy , legalistic section on privacy may make these already complex documents even le ss user-friendly for patients who are asked to read and sign them. These data suggest that the HIPAA privacy rule, as currently implemented, may be having negative impacts on the cost and quality of medical research. Dr. Kim Ea gle, professor of internal medicine at the University of Michigan, was quoted in the Annals article as saying, "Privacy is important, but research is also impor tant for improving care. We hope that we will figure this out and do it right."[

32] [edit] Effects on clinical care The complexity of HIPAA, combined with potentially stiff penalties for violators , can lead physicians and medical centers to withhold information from those who may have a right to it. A review of the implementation of the HIPAA Privacy Rul e by the U.S. Government Accountability Office found that health care providers were "uncertain about their [legal] privacy responsibilities and often responded with an overly guarded approach to disclosing information...than necessary to e nsure compliance with the Privacy rule".[32] Reports of this uncertainty continu e.[35] [edit] Costs of implementation In the period immediately prior to the enactment of the HIPAA Privacy and Securi ty Acts, medical centers and medical practices were charged with getting "into c ompliance". With an early emphasis on the potentially severe penalties associate d with violation, many practices and centers turned to private, for-profit "HIPA A consultants" who were intimately familiar with the details of the legislation and offered their services to ensure that physicians and medical centers were fu lly "in compliance". In addition to the costs of developing and revamping system s and practices, the increase in paperwork and staff time necessary to meet the legal requirements of HIPAA may impact the finances of medical centers and practices a t a time when insurance company and Medicare reimbursement is also declining.

Accumulator Component Code - indicates what dollars will be accumulated as indic ated in this field Option 29 Plan Benefit (RxCLAIM) Valid values are: 1=Deductible 2=Deductible+Copay 3=Patient Pay 4=Patient Pay (After Adj Date) 5=Post Deductible 6=Post Deductible + Copay 7=Post Patient Pay 8=Post Patient Pay (After Adj Date) 9=Post Deductible (After Adj Date) A=Post Copay B=Post Copay + Product Selection Penalty C=Post Deductible + Copay + Product Selection Penalty D=Post Copay (After Adj. Date) Day4 ======= Bank Identification Number (BIN) Each PBM platform has their own BIN number. Th is is used by the switching station to send the transaction to the correct PBM p latform. CVS Caremark s BIN numbers are: QL = 610029 RECAP = 610415 RxCLAIM = 004336

Batch Claim The process by which a group of processed claims need to loaded. It arrives in the form of sequential files that may be sourced from a client or a g overnment agency/vendor. It can be used when a new client comes into Caremark an d needs to load historical claim data. It is also used when a group of claims n eed to be reversed and resubmitted (R&R) in order to correct something on the cl aim due to volume

strategies/Functionalities of PBM: 1. Create and maintain Formulary 2. Tier copay 3. Generic Substitution 4. Manufacturer discount 5. Retail Pharmacy rebate 6. Prior authorisation 7. DUR 8. Mail order pharmacy drug coverage: what r type of drugs should be covered is mentioned in the plan. pharmacist needs authorisation in order to dispence that particular from the car rier/ in the data base of PBM Formulary: it is a list of approved drugs by FDA. P&T commmitte: Pharmateucal & Therapeutic commiittee: creates the formulary base d on the effectiveness, safeness and cost of the drugs. Each is having their separate P&T committe the member of P&T includes the the board of directors of PBM, providers,speciali sts. Based on the feedback of DUR,DDI they design the formualry FRC: Formulary review committee: reviews the formulary FDA: Food & Drug Admin: under the FED govt types of drugs: 1.Formulary 2. Non formulary how many of types of formulary: 1. OPen : both form and non form drugs should be included in this 2.closed : member is restricted only to the form drugs 3. Mixed/ managed: DUR:Drug utilisation review: the extent a drug is utilised by the patient or pr escribed by the prescriber DDI: drug to drug interaction. according to Formulary, drugs r categorised into 3 types: 1. Generic : tier 1 : copay is least 2. Preffered brand :tier 2 is more that tier 1 3. Non preffered brand :tier 3 is having highest copay Drugs r coming from the 3 sources: 1. FDB:First data bank 2. Micro medix 3. Medispan QL: quantum leap RECAP:remote electronic claim adjudication process PDL: preffered drug list (This refers to medications that may be on a formulary in a multiple tier benefit design that allows for co-payment at the time of serv ice equal to that charged for second-tier or midlevel cost. For example, a pati ent would pay the next highest co-payment for the preferred drug after the gener

ic co-payment amount, not the highest co-payment overall in the benefit plan) DAW: dispence as written (An order on a prescription commanding the pharmacist t o provide the recipient with the prescription exactly as it was written) GPI: generic product identifier : RxClaim (A fourteen digit hierarchical number that is used to classify drugs into therapeutic categories. One GPI may be rela ted to many NDC Id s. Only one number per generic, covers all forms of the drug, t herapeutic classification scheme for drug interaction & allergy checking and pla n edits) NDC: national drug code: RxClaim, REcap GCN: generic code number : Recap (Non - unique, The Generic Code Number (GCN) is a random number representing the generic formulation. The GCN is specific to g eneric ingredient combination, route of administration, dosage form and drug str ength. The GCN is the same for all manufacturers and/or package sizes) AWP:average wholesale price ARP: average retail price ========================================================================= General Info: Some consumer driven health care plans: 1 . Discount Drug Card: Discount drug cards offer discounts on various me dical services including medicine. They are not a form of insurance. Some are fr ee while others may involve a hefty fee. They are offered by state governments, drug companies, non-profit and for-profit businesses. 2. Health Spending Account : A health savings account (HSA), is a tax-ad vantaged medical savings account available to taxpayers in the United States who are enrolled in a High Deductible Health Plan (HDHP)( A high-deductible health plan (HDHP) is a health insurance plan with lower premiums and higher deductible s than a traditional health plan.). Employer-funded plans that reimburse employees for incurred medical expenses tha t are not covered by the company's standard insurance plan. Because the employer funds the plan, any distributions are considered tax deductible (to the employe r). Reimbursement dollars received by the employee are generally tax free. 3. IRA: An individual retirement arrangement (IRA) is a form of retireme nt plan (The terms retirement plan or superannuation refer to a pension granted upon Retirement plans may be set up by employers, insurance companies, the gover nment or other institutions such as employer associations or trade unions) that provides tax advantages for retirement savings in the United States. The term en compasses an individual retirement account a trust or custodial account set up f or the exclusive benefit of taxpayers or their beneficiaries and an individual r etirement annuity, by which the taxpayers purchase an annuity contract or an end owment contract from a life insurance company. 4. HRA: Health Reimbursement Accounts or Health Reimbursement Arrangemen ts (HRAs) are Internal Revenue Service (IRS- The IRS is responsible for collecti ng taxes and the interpretation and enforcement of the Internal Revenue Code.)-s anctioned programs that allow an employer to set aside funds to reimburse medica l expenses paid by participating employees. Using an HRA yields "tax advantages to offset health care costs" for both employees as well as an employer. 5. FSA: A flexible spending account (FSA), also known as a flexible spen ding arrangement, is one of a number of tax-advantaged financial accounts that c an be set up through a cafeteria plan (A cafeteria plan is a type of employee be nefit plan offered in the United States pursuant to Section 125 of the Internal Revenue Code.) of an employer in the United States. An FSA allows an employee to set aside a portion of his or her earnings to pay for qualified expenses as est ablished in the cafeteria plan, most commonly for medical expenses but often for dependent care or other expenses. Money deducted from an employee's pay into an FSA is not subject to payroll taxes, resulting in substantial payroll tax savin gs. One significant disadvantage to using an FSA is that funds not used by the e nd of the plan year are lost to the employer.[1]

Some terminologies related to Pricing of drugs: Maximum Out-of-Pocket (Max. Out-of-Pocket or MOOP) The maximum out-of-pocket is the limit, or ceiling, on your costs for medical ca re within the insurance plan year. Once the applicable Yearly out-of-pocket maxi mum is reached, you pay nothing for covered prescription drugs for the remainder of the calendar year. Maximum Rx Out-of-Pocket The maximum Rx out-of-pocket is the limit, or ceiling, on your costs for prescri ptions within the insurance plan year or for a given prescription. This maximum may vary by prescription tier or level. Average Wholesale Price (AWP) The average or most common price a retail pharmacy would pay a wholesaler to buy a specific quantity of a drug. It is the composite wholesale price charged on a specific commodity. It is always an Over ??????amount of AAC. Ingredient Cost: Total cost of the individual elements used in preparing the drug Dispensing Fee: The amount paid to a pharmacy for distributing each medi cation in addition to the medication ingredient cost. Patient Pay: This is the total amount paid by the patient i.e. sum of co pay+deductible+some additional tax Withhold Amount: Withholds are amounts held back from a pharmacy at the time of payment, and given back at a later date, perhaps for compliance purposes or administrative fees, for example. Enter a flat dollar amount to withhold, e. g. .12 = $0.12 Deductibles : The amount specified in each plan design that a member mus t pay out of pocket before becoming eligible to use plan benefits. After the de ductible is met, play co-payments (if any) will apply Actual Acquisition Cost (AAC) The price a pharmacy actually pays for a d rug. The net payment by a pharmacy to purchase a medication after allowances, d iscounts or rebates. Administration Fees drug. Administrative Costs Costs incurred by a provider or insurance organizat ion for services such as overhead, billing and claims processing expense, and ot her management services related to the delivery of health care services. Allowable Charge ider. Maximum Allowable Cost (MAC) This is an upper limit price that an insure r or health plan will reimburse for generically available or multiple source med ications. This typically follows the initiative for reimbursement by the Medica re and Medicaid program when more than two generic drugs are available in the ma rketplace. CCW - Caremark Calculated WAC. This price is set by CVS Caremark to be u The maximum fee (charge) allowed for payment to a prov A physician s charges for injecting or administering a

sed for those drugs that do not have a WAC price. When a client elects to use WA C pricing we will also set up CCW. When a drug with no WAC price is submitted th e CCW price will be used in the calculation to price the claims. U & C Usual and Customary is the lowest price the pharmacy would charge if the customer were paying cash for an identical prescription on that particula r day. This price must include any applicable discounts offered by the pharmacy to attract customers. WAC - The manufacturer charges this amount to the wholesaler (pharmacy) to purchase the drug. It is a published price and does not generally reflect any rebates or discounts. It is often referred to as the catalogue price. Not all N DCs have a WAC price. Insurance Information: HMO/PPO Provider List Following is a list of the HMOs and PPOs accepted by the Department of Ophthalmo logy and Visual Sciences Clinics. The clinics will also see patients on a fee-fo r-service basis. If you have any questions about your insurance coverage, please contact your ins urance provider directly. Type Organization Name PPO ADMAR (formally Principal PPO) HMO ADVOCATE HEALTH PARTNERS HMO/POS AETNA HMO/POS - UIC HMO/POS AETNA HMO (HMO/QPOS) POS AETNA POS (Elect Choice and Managed Choice) PPO AETNA PPO/EPO (Open Choice and Traditional) HMO AMERIGROUP ILLINOIS, INC PCP CAP - MILE SQUARE ONLY PPO BEECH STREET PPO PPO BLUE CROSS BLUE SHIELD (BC/BS) PPO Medicare Select BC/BS MEDICARE SELECT POS BC/BS BLUE CHOICE Student Program CAMPUSCARE PPO CARLECARE PPO (FORMERLY HEALTH ALLIANCE PPO) PPO CCN/EPIQUAL HMO CIGNA HMO POS CIGNA POS PPO CIGNA STATE OF IL (QCHP) WC CORVEL/ CORCARE PPO EVOLUTIONS HEALTHCARE SYSTEMS PPO FIRST HEALTH PPO GIA-GROUP INSURANCE ADM GLOBAL GLOBAL/PACKAGE CONTRACTS HMO HARMONY HEALTH PLAN (Commercial) HMO HARMONY HEALTH PLAN (Medicaid) PCP CAP - MILE SQUARE ONLY HMO HEALTH ALLIANCE HMO PPO HEALTH MARKETING INC PPO PPO HEALTH NETWORK PPO/WELLMARK PPO HFN - HEALTHCARE'S FINEST NETWORK EPO HFN - HEALTHCARE'S FINEST NETWORK EPO HMO HMO ILL-UIC (SITE 141) HMO HMO-ILLINOIS HMO/EPO HUMANA NATIONAL HMO POS HUMANA POS HMO HUMANA HMO - UIC HMO HUMANA HMO HMO HUMANA ACCESS PPO HUMANA PPO

Medicare Select JBC PLATINUM Medicare Select JBC GOLD PPO MULTIPLAN HMO/PPO NOT CONTRACTED HMO or PPO PPO PNA - PREFERRED NETWORK ACCESS PPO PPONEXT PPO PREFERRED PLAN PPO PRIVATE HEATLHCARE SYSTEMS (PHCS) PPO SAGAMORE HEALTH NETWORK PPO THREE RIVERS PROVIDER NETWORK HMO UNICARE HMO HMO UNICARE (formerly RUSH PRUDENTIAL) HMO - UIC POS/PPO UNICARE POS/PPO HMO UNION HEALTH SERVICE HMO UNION MEDICAL CENTER PSYCH UNITED BEHAVIORAL HEALTH HMO/PPO/POS UNITED HEALTH CARE (formerly: CHICAGO HMO) PPO UNITED OPEN ACCESS HMO UNITED MEDICAID HMO-UIC United Medicaid HMO=UIC Clinic Site: 372 =Mile Square HMO UNITED HEALTH CARE MEDICAID TRANSPLANT UNITED RESOURCE NETWORK