What term describes any payer other than the patient who reimburses a pharmacy for prescription costs?

A third-party payer. This includes insurance companies, government programs (Medicare, Medicaid), and pharmacy benefit managers (PBMs).

What is a Pharmacy Benefit Manager (PBM)?

A PBM is an intermediary company that manages prescription drug benefits on behalf of insurers, employers, or government programs, and negotiates drug pricing and formularies.

Which federal program provides prescription drug coverage through Medicare Part D?

Medicare Part D is a voluntary federal program that provides outpatient prescription drug coverage to Medicare-eligible individuals through private insurance plans.

What is a formulary in the context of pharmacy insurance?

A formulary is a list of prescription drugs covered by an insurance plan, often organized by tiers that determine the patient's co-pay amount.

What is the standard electronic format used to submit pharmacy claims to insurance companies?

The NCPDP (National Council for Prescription Drug Programs) D.0 transaction standard is used to electronically transmit pharmacy claims to payers.

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