Common Terms

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1-month supply

The amount of medicine you use during a 1-month period. In most cases, your doctor will prescribe a 1-month supply or less for short-term medicine.

3-month supply

The amount of long-term medicine you use during a 3-month period. In most cases, prescriptions for long-term medicine are written for a 3-month supply. The actual quantity or days' supply you receive depends on your plan’s rules.

B

Benefit

A term used to refer to the services covered by your health insurance. Express Scripts manages your “pharmacy benefit” for your employer, your health plan, or your plan sponsor. Learn about your pharmacy plan details in Benefits Overview.

Brand-name drug

Medicine that is sold by a company under a specific name or trademark and is protected by a patent.

C

Caregiver

A paid or unpaid person who helps with any needs required by someone who can’t meet his/her own needs. This covers a broad spectrum of needs, ranging from daily living tasks (eating, bathing, dressing) to helping with tasks on an as-needed basis (such as running errands). If you want a caregiver to be able to manage your medicines and your Express Scripts online account, you must make him or her a “designated caregiver” using the Add a Caregiver page in the Accounts menu. If you are a caregiver and hold a person’s power of attorney (POA), your client still must designate you as a caregiver using the Add a Caregiver page in the Accounts menu.

Catastrophic Cap

The maximum amount of Out-of-Pocket expenses allowed per the fiscal/enrollment year. The Out-of-Pocket expenses are defined as: enrollment fees, deductibles, cost shares, and co-payments. This includes out-of-pocket claims for both medical and pharmacy coverage.

Claim

A request for payment submitted to your health insurance by you or by your healthcare provider. This request is for any services you think might be covered by your plan.

Coinsurance

The partial cost you pay for your medicine, each time you fill a prescription. The amount you pay is set by your plan and is a percentage of the total cost. Learn about your plan’s details in Benefits Overview.

Example

  • The price of your medicine is $100.
  • Your coinsurance is 20%.
  • You pay $20 for the medicine.

Your coinsurance is different from your copayment, or copay. Learn about copay.

Compound drug

Medicine with different ingredients combined together in order to tailor it for individual needs. Once mixed together, compound drugs are not FDA-approved.

Confirmation number

The number we apply to every order that you place. This number helps us find your order in our system if you need to ask us about your order.

Controlled substance

A term used only for medicines or illegal drugs that have a high risk for causing harm. It means the medicine requires a doctor’s prescription and that its use is restricted by law (the Controlled Substances Act). The term covers medicines, such as opioid drugs. It does not apply to tobacco or alcohol.  

Coordination of benefits (COB)

If you are covered by two or more health plans, this process decides the amount each plan pays for a claim.

Copayment (Copay)

A set dollar amount you pay out of your own pocket for your medicine. Your copay is set by your plan. Learn more about your plan’s details in Benefits Overview page found in the Benefits menu.  

Your copay is different from your coinsurance. Learn about coinsurance

Courtesy fill

If you take a medicine to treat a long-term condition (one that lasts 3 months or longer), then your prescription plan might use certain rules that affect the price of your medicine and the way you get it. A “courtesy fill” is the number of fills and refills you can order, before these rules fully take effect.

These rules include factors such as the medicine type, form, amount you get, what pharmacy or pharmacy network you use, and others. After you’ve used your “courtesy fills” limit, you’ll need to follow your plan’s rules for getting your medicine in order to avoid paying a higher price for it. 

Coverage review

See Prior Authorization (PA).

D

Days’ supply

The number of days’ worth of medicine your doctor prescribes for you. There are limits for the maximum number of days, based on the type of medicine, why you’re taking it, and your prescription plan’s rules. 

  • If your plan includes delivery of long-term medicines, your doctor will prescribe the maximum days’ supply allowed by your plan.
  • If your plan includes the option to fill certain long-term medicine through local network pharmacies, you can check coverage and pricing using our Price a Medication tool in the Prescriptions menu, and we’ll set your days’ supply to the maximum allowed by your plan.

Deductible

The total amount you must pay before your plan starts paying for part of your prescription costs. This amount varies by plan. Learn about your plan’s details in the Benefits Overview page found in the Benefits menu.  

E

e-Prescribing

This is a process doctors can use to send a prescription to a pharmacy using a secure computer network.

Extended payment program (EPP)

This lets you pay for your delivery prescriptions in three monthly payments (installments), instead of paying the full amount all at once. Each monthly payment is automatically processed using your preferred payment method.

Example: you order a prescription that costs $90 and your preferred payment method is a credit card. Under the EPP, you would make 3 monthly payments as follows:

  • First payment: As soon as your prescription ships, we’ll charge your card $30.
  • Second payment: 30 days after your prescription ships, we’ll charge your card another $30.
  • Third payment: 60 days after your prescription ships, we’ll charge your card the final payment of $30.
Triangle to get user attention

 EPP does not cover expedited shipping costs. If you select expedited shipping for your order, the total shipping cost will be billed with your first payment.

F

Formulary Search Tool

An online tool you can use to:

  • locate pharmacies where you can get your prescription filled
  • see how much it costs
  • find out if your prescription requires a prior authorization (PA)
  • look up any medical necessity criteria
  • get these forms, if needed, for your prescription:
    •  prior authorization (PA) form
    •  medical necessity form 

G

Generic drug

A prescription or over-the-counter (OTC) medicine that has the same active ingredient as a brand-name version that’s on the market. Generic drugs often are a lower-cost option to their brand-name versions. They can be identical to the brand-name drug or a:

  • generic equivalent: it’s similar to the brand-name drug and has the same active ingredient, but has different inactive ingredients.
  • generic alternative: it has a different active ingredient from the brand-name drug, but a similar clinical effect on the body.

You can find out more about generic drugs from the US Food and Drug Administration

H

Health insurance

A contract that requires your health plan to pay some or all of your healthcare costs in exchange for a fee (this is called a “premium”). Your health insurance is divided into two parts:

  • services — this includes things such as doctor appointments, hospital visits, and some medical supplies.
  • prescription medicines — this includes your medicine and supplies related to your prescription. Your prescription plan from Express Scripts (also called a “pharmacy benefit”) is the part that covers your prescription medicines and supplies. 

I

Invoice number

The number we place on your package when we ship medicine to you. If your order ships in more than one package, then you will have more than one invoice number.

J

K

L

Licensed pharmacist

A person with special training about medicines, and licensed to practice by a national and state board. Express Scripts pharmacists are licensed and many have extra training to give advice about medicines to treat:

  • Asthma
  • Arthritis
  • Cancer
  • Depression
  • Diabetes
  • Heart disease
  • High blood pressure
  • High cholesterol
  • Migraine headaches
  • Women's health conditions

Long-term medicine

Any medicine you have to take for three or more months to control symptoms or to prevent complications from a condition. Examples of conditions that might require long-term medicine include: high blood pressure, high cholesterol, diabetes, arthritis, heart conditions, and long-term pain.

M

Maintenance medicine

Another term for “long-term medicine.”

N

National Drug Code (NDC)

A unique number the US government assigns to every prescription and over-the-counter (OTC) medicine on the market. The code refers to the strength and dosage form (such as liquid, tablet, capsule, etc.) and to those who make or distribute it. This number is required on the Express Script Prescription Drug Reimbursement / Coordination of Benefits Claim Form.

Non-formulary medicine

A medicine not listed on the Uniform Formulary list Drugs not on the list are considered to be less clinically effective and/or less cost-effective than other drugs in the same drug class. You pay a higher share of the cost for these drugs.

O

One-month supply

The amount of medicine you use during a one-month period. In most cases, your doctor will prescribe a one-month supply or less for short-term medicine.

Other health insurance (OHI)

Any health insurance you have in addition to TRICARE (such as insurance through your employer or through a private insurance program.

Out-of-pocket expense

The money you pay out of your own pocket for your medicine before your plan covers the rest of the cost.

P

Pharmacy benefit manager (PBM)

An organization that manages the pharmacy portion of health plan coverage to make sure the use of medicine is safer and more affordable. Express Scripts is a PBM and a member of the national association of PBMs, the Pharmaceutical Care Management Association.

Pharmacy network

A group of pharmacies that work together to help keep the cost of your medicine as low as possible. In most cases, you’ll pay less for medicine from an in-network pharmacy than from a pharmacy outside of your network.

Plan year

A 2-month period of coverage under a group health plan. This 12-month period might not be the same as the calendar year.

Policy year

A 12-month period of coverage under an individual policy. This 12-month period might not be the same as the calendar year.

Premium

The amount you pay for your health insurance coverage, either in a lump sum or through installments.

Prescription (Rx)

The written instruction for medicine that a licensed medical professional provides. The abbreviation for prescription is Rx.

Prevention

Steps taken to prevent illness; for instance, routine check-ups and screenings.

Primary care

Health services that cover a range of prevention, wellness, and treatment for common conditions and injuries. Primary care providers include general practitioner doctors (GPs), nurses, and physician assistants.

Prior authorization (PA)

Also known as a “coverage review,” this is a process health plans might use to decide if your prescribed medicine will be covered. Plans use this to help control costs and to ensure the medicine being prescribed is an effective treatment for the condition.

Q

Quantity Limit

The maximum amount of a medicine a health plan covers during a certain period of time. These limits are set for safety reasons and to help reduce costs. If your doctor prescribes more medicine than your plan allows, the doctor will have to contact the plan to approve the amount.

R

Referral

A written order from your primary care doctor for you to see a specialist or to obtain certain medical services. If you don’t get a referral first, your plan might not pay for the services.

Refill

When your doctor writes your prescription, it might include a certain number of refills. This means you can continue to get the medicine refilled until the prescription expires. Once your prescription expires, it requires a renewal before you can get another refill.

Renewal

After a prescription expires, a doctor needs to renew it. A renewal is a new prescription, even though it might be for the same medicine and the same dose you’ve been taking. Your doctor might want you to schedule an appointment or get some test results, before renewing your prescription. This helps make sure the medicine is still treating your condition as it should. Although many people think of a renewal as just another refill, a renewal is different because it’s a new prescription.

Rx number (prescription number): a unique number given to every prescription. You’ll find the number on the prescription label.

S

Specialty pharmacy

Specialty medicine is used to treat complex and long-term conditions, and usually has to be stored or handled in special ways. People take specialty medicines for conditions, such as multiple sclerosis, rheumatoid arthritis, or hemophilia. If you're taking a specialty medicine, you can find services through the Specialty Medication Care Management Program

Step therapy

A process designed to help control high medicine costs. If your plan applies step therapy to your prescription, it will require that you try a lower-cost medicine that’s proven effective to treat your condition, before it will cover a higher-cost medicine. If the lower-cost medicine does not treat your condition effectively, your plan’s coverage will “step” you to a higher-cost medicine to find a medicine that treats your condition effectively at the lowest possible cost.

T

Total annual co[payment

The total copay amount you spend on prescriptions during a one-year period.

Example:

  • Your copay is $7 for a 3-month supply of medicine with delivery from TRICARE Pharmacy Home Delivery.
  • You fill this medicine every three months, which is 4 refills per year.
  • Your total annual copay is $7 x 4 = $28.

Total daily dose

The total amount of a medicine you take in a 24-hour day. You’ll need to know this number in order to get pricing details for your medicine using our Price a Medication tool.

To calculate your total daily dose, multiply the amount of medicine by the number of times you take it every day.

Example

  • You take 2 tablets 4 times per day.
  • Your total daily dose is 2 x 4 = 8.

U

Uniform formulary

All drugs are divided into different “classes” (known as “therapeutic classes”) according to how they work in the body. A “formulary” is a list of the medicines considered to be the most effective for treatment and/or the most cost-effective drugs in those classes.

The list is created by the DoD Pharmacy & Therapeutics (P&T) Committee, a group of pharmacists and doctors that reviews medicines approved by the US Food and Drug Administration (FDA). This group then recommends whether a drug should be placed on the list (”formulary”) or not placed on the list (“non-formulary”). The formulary includes both brand-name and generic drugs

For instance, drugs that are just as effective but cost more, compared with other drugs in the same class, might be placed in the non-formulary list. Drugs on the non-formulary list are available to beneficiaries, but at a higher copay amount. 

Looking for more information about any of the terms in this list? You can find useful definitions for many terms at HealthCare.gov/glossary.

V

W

X

Y

Z

If you can’t find the answer to your question, please contact us.