Chapter 13 - Managed Care Flashcards
What percentage of Americans are now covered under managed healthcare?
Almost 80%.
Effective drug therapy is a cost effective and highly valuable means of controlling total healthcare expenditures and improving quality of life. True or false?
True.
Formulary
List of prescription drugs approved by insurance coverage.
Drug Utilization Review (DUR)
Involve retrospective monitoring of physicians’ prescribing patterns.
How far back does the history of formularies extend?
The American Revolution.
Open formulary
List of virtually all medications in a broad range of therapeutic classes, and place few restrictions on coverage or access.
Closed formulary
More restrictive, typically limiting the number of medications in each therapeutic class and subjecting certain medications to restrictions and exception procedures.
Tier 1
Lists generics. Usually less expensive for the plan.
Tier 2
Lists preferred brands. Generally less expensive brands or brands designated as ‘preferred’ by the plan because of incentive contracts with manufacturers.
Tier 3
Lists non-preferred brands. Typically higher cost medications.
Advantaged position
Your product is advantaged when its in the preferred position (Tier 2). Exclusive preferred status if product has unique clinical or cost advantage.
Neutral position
At parity with other brands within the tier.
Disadvantaged position
Usually when a drug has been assigned to Tier 3.
Opportunity cost
The value of the sacrificed alternative.
What are the primary entities that fund pharmaceuticals?
Employers, the government, and individuals.
