Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Health-Care Systems > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

What is a PBM

A

Pharmacy benefit manager
Private companies that specialize in Rx drug claims and coverage
administrative services only
assume no financial risk

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

what do PBMs do

A

contract and build networks of retail pharmacies from which patients can purchase their prescriptions
formulary development and management
Utilization and cost management
Claims processing and provider payment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

what is the equation of prescription payment from PBM

A

Rx Payment from TTP (third party payer, in this case PBM)=
product cost + dispensing fee - patient share cost

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

what is used to calculate the product cost for single source, brand name drugs

A

Estimated acquisition cost (EAC)=
AWP- (AWP(x%))

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

what is used to calculate the product cost for multisource, generic drugs

A

Maximum allowable cost (MAC)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

If a drug has a brand name and generic name drug available, and the Rx is written for the brand name drug, what variable do you use to calculate the product cost

A

EAC because you must dispense the rx as written for the brand even though generic is the cheaper default option

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Define WAC

A

Wholesale acquisition cost
manufacturer’s published list price for sale of a drug (brand or generic) to wholesalers
WAC is approx for what pharmacies pay wholesalers for BRAND-NAME drugs
exceeds pharmacies’ acquisition costs for generics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

AMP

A

Average manufacturers’ price
average price actually paid to manufacturers by wholesalers for drugs in retail pharmacies or for drugs bought directly from manufacturers
Used by gov’t as estimate for Medicaid generic Rx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

AWP

A

average wholesale price
suggest list price for products purchases from wholesalers sold to pharmacies
pricing index to determine the pharmacy payments from PBMs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

AAC

A

Actual acquisition cost
actual amount paid by a pharmacy to supplier for a product
typically unknown so rarely used for determining reimbursement amounts under Rx benefit plans

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

EAC

A

estimated acquisition cost
estimate of AAC use to determine reimbursement amount for single source drugs
EAC = AWP- AWP (%)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

MAC

A

maximum allowable cost
max amount per unit of meds that PBMs will pay pharmacies for multisource drugs, regardless of amount pharmacy actually paid
creates incentive to spend less on generics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

what are the 8 mechanisms PBMs use to control drug costs and increase their revenue

A

spread pricing
rebate with drug manufacturer
formularies
prior authorizations
quantity limits
step therapy
generic drug use
mail service options

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

define spread pricing

A

bill health plans more for Rx claims than pharmacy is reimbursed for its product costs and dispensing services

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

define rebate
what are the two forms of it

A

To the PBMs from manufacturers for single source brand name drugs to encourage PBMs to increase the market share for a specific med
Two forms: flat rate rebate and market share

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

define flat rate rebate

A

rebate based on a fix percent of the WAC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

define market share rebate

A

rebate amount based on market share each PBM achieves for specific product
increased by the PBMs promotion of drug
lower co-pays
market share = # Rx for specific drug / # Rx for entire drug class
both covered by PBM

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Formulary

A

list of medication covered by third party payer
includes tiered copays
lowest copay for generics
brands
nonpreferred brands
highest copay for specialty drugs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Prior authorizations

A

providers must get approval from insurance showing the patient meets specified criteria before the patient can receive the drug
criteria includes contradictions/allergies to preferred medications, failed prior treatment with preferred medication
delay in patient access or prescribing less effecting med to avoid hassle can result
very time intensive for provider and pharmacy staff

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

quantity limits

A

limits on # days supply or number of dosage units of medication allowed per Rx or time period

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

step therapy

A

prescribing pattern/protocol using the most cost-effective drug first

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

generic substitution

A

use of the generic drug if available, some cases only the generic will be covered

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

mail service options

A

option offered by prescription benefit plans where enrollees can pay lower cost-sharing amount and are able to obtain greater quantities

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

How are retail pharmacies reimbursed for prescription drugs under Medicare? Single source and multisource?

A

through stand-alone Part D (PDP) or medicare advantage prescription drug plans (MA-PD)
both are administered by private insurance companies that reimburse retail pharmacies for Rx drugs through PBMs using the same standard formula
Single source use EAC
Multisource use MAC subject to FUL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Describe FUL
Federal Upper Limit States that receive federal funding for Medicaid can't pay more than the federal upper limit for multi-source generic drugs published by Center for Medicare and Medicaid Services (CMS) Calculated using AMP
26
What are the roles of drug wholesalers
prime vendors; intermediates in the drug supply line like the PBM in the reimbursement line
27
why do pharmacies use drug wholesalers
reduce number of invoices reduce inventory with multiple deliveries per day Improved cash flow
28
Group purchasing organizations
group of health organizations in community or hospital setting that are brought together to provide large numbers that can leverage purchases and negotiate drug prices
29
Pros of open channel drug distribution
maximize access to drugs for patients with relatively common diseases
30
Cons of open channel drug distribution
manufacturers have little control over inventory delay in delivery on information about prescribing patterns or patient outcomes
31
Pharmacy Benefits
bill and dispense NDC: specific drug name, manufacturer, form, strength, container copayment or coinsurance for drug cost controls (better coverage for generics, quantity limits, prior authorizations, step therapy
32
Medical Benefits
Buy and bill: Purchase administer, bill HCPCS Code (specific drug/drug class but not manufacturer, strength, package size) copayment for office visit, no cost-share for drug no price differentiation between generic and brand, weak control
33
Specialty Drugs
Expensive and require more clinical attention high cost treat rare conditions injectables (usually) produced via biotech (usually) requires therapy management by HC professional (high incidence of adverse effects and compliance problems FDA required REMS
34
2 drivers of specialty drug trend
high cost per patient increased utilization (more drugs off drug pipeline, earlier use of biologics in regimens, new indications)
35
Limited drug distribution
Small number of distributors: drug only in few specialty pharmacies or wholesalers patients with relatively rare conditions Specific drug shipped for specific patient
36
REMS
risk evaluation and mitigation strategy for drugs with potential serious adverse side effects developed by manufacturer and approved by FDA Requires data on distribution, prescribed, dispensed, and taken
37
How does specialty pharmacy benefit manufacturers
consistent data for REMS from pharmacy better control inventory, reduced distribution costs, predicting market needs increased access to patients through co-payment assistance and patient education
38
Patient benefit of specialty pharmacy
quick access to drug 24 hr access to pharmacist for questions finding patient assistant programs to overcome financial barrier member education drug use refill and monitoring calls clinical programs (disease management)
39
Insurer benefit of specialty pharmacy
shifting to white bagging which allows them to enact more cost controls receive data from specialty pharmacy about how expensive drugs are utilized (prescribing patterns, patient adherence, effect of cost-control mechanisms)
40
what are both types of pharmacy practice trying to achieve
improve patient's health outcomes
41
clinical pharmacy
product based care focused on application of knowledge patient counseling therapeutic drug monitoring by pharmacist
42
pharmaceutical care
introduced in the 1990s patient centered outcome oriented requires inter-professional cooperation disease management medication therapy management
43
3 reasons for the shift to patient centered care
patient compliance: understanding health background and cultural context improves adherence prevalent chronic conditions: increase value on quality of life managed care cost-containment strategy: cheaper to prevent diseases than treat serious illness
44
Under OBRA ’90, pharmacists are expected to offer an explanation of the prescription drug regarding…?
purpose proper administration common adverse effects potential interactions contraindications to use of drug guidance on steps to take given specific outcomes
45
General information about patient counseling including the way pharmacists are paid for the service.
no proper payment structure or compensation following directions and optimizing health is ultimately up to patient need yes or no if counseling was offered no follow up required
46
disease management
coordinated health interventions for the define patient populations with chronic conditions interprofessional need significant self care addresses patient's drug and nondrug therapy, lifestyle modifications no adequate compensation; service reimbursement under physician in inter-professional team
47
what law created MTM
Medicare Prescription Drug Improvement and Modernization Act of 2003
48
Goal of MTM
optimize therapeutic outcomes through improved medication use, and to reduce the risk of adverse events including adverse drug interactions
49
CMS guidelines
Guidelines: NOT services of patient counseling or disease management, they didn't further elaborate, very unclear Eligibility
50
eligibility of MTM
multiple chronic disease states taking multiple medications spend more than a specified amount on Rx meds
51
five core elements of MTM
comprehensive medication review (CMR): pharmacist asses all current medications personal medication record (PMR): record for the patient of all of their medications medication related action plan (MAP): document for the patient to use in tracking progress for self-management intervention/referral: medication related problems if present documentation and follow-up: evaluate patient progress and billing purposes
52
Patient counseling vs. MTM
patient counseling: required, no documentation required, rx specific, not wholistic, no formal payment MTM: only required for Medicare Rx drug plans, requires documentation (for follow up and billing), wholistic, has follow up, can bill for service
53
what does gaining the “provider status” means for pharmacists
able to make claims directly to third-party payer for services they provide and the value of those services is properly recognized
54
Rational for pharmacists to obtain provider status
Need primary care service providers in medically underserved areas many patients with chronic diseases managed by chronic medications movement toward pay-for performance through coordinated care, team-based approach
55
What are the 3 efforts on the Federal pathway to attaining provider status
Amending Social Security Act to list pharmacists as a provider Pharmacy and Medically Underserved Areas Enhancement Act: all ow pharmacists to deliver care to patients in federally defined medically underserved communities Equitable Community Access to Pharmacists Services Acts: establish Federal reimbursement mechanism for pharmacists services under Medicare Part B; allow for testing, treatment, and vaccinations
56
What are the 3 areas pharmacists try to improve at the state level for provider status
provider designation scope of practice recognition by payers
57
Rule 89
Pharmacists procurement of drug products insuring their strength, quality, purity, and labeling from licensed and lawful distributors accurate interpretation and dispensing associated with legal and legitimate prescriptions Shall not fill an Rx where improperly written susceptible to more than one interpretation where there is reason to believe it will harm the patient where there is reason to believe it will be used for other than legitimate medical purposes communicate to patient or patient caregiver (patient counseling)
58
Describe the different roles and responsibilities of pharmacist and technician.
pharmacist can delegate some of their tasks to licensed or unlicensed person if the pharmacist determines knowledge and skills necessary determine delegate posses knowledge and skills provides policies and procedures for these functions supervise and evaluates the delegate provides remediation and pharmacist bear the ultimate responsibility for performance of delegated tasks and functions
59
Licensed nurse on duty 24 hrs a day and higher level of care
skilled care/hospital like
60
more regulations and mandated monthly pharmacist chart review
hospital like/skilled care
61
costs about $6400 but is typically paid for by managed care
hospital liked/skilled care
62
staffed by medical assistants and has higher functioning patients
home-like/assisted living
63
no mandated pharmacist chart review
home-like/assisted living
64
licensed nurse on-call or present
home-like/assisted living
65
average cost $3500 and paid for out of pocket
home-like/assisted living
66
Part A coverage of activities of daily living
skilled care after hospital stay day 1-20: $0 copay day 21-100: $161/day copay day 101+: no part A coverage
67
Part B and D coverage of activities of daily living
After 100 days: Part B or D does not cover activities of daily living Part B only covers physician services and durable medical equipment Part D pay for Rx
68
What will Medicaid cover
Activities of daily living (ADLs) medications other necessary services and equipment NOT ALL facilities accept Medicaid Patients must meet asset/income requirements
69
Who is subject to strict annual inspections by the state
skilled care nursing facilities

Health-Care Systems (3 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions