Managed Care (AMCP Article)

Question 1

Managed Care Pharmacy Overview

Answer 1

Managed Care Pharmacy emphasizes quality care and cost-effective coverage.

Pharmacists play a pivotal role in utilizing tools like Electronic Prior Authorization, Step Therapy, Medication Therapy Management, and Mail Service Pharmacy.

Question 2

Formulary Development:

Answer 2

Managed by Pharmacy & Therapeutics (P&T) Committees.

Involves continuous development, management, and updating of formularies.

Question 3

Pharmacist Education:

Answer 3

Pharmacists complete a Doctor of Pharmacy (PharmD) degree, with a focus on pharmaceutical education.

Many pursue further training through residencies and fellowships.

Question 4

Pharmacist Lifelong Learning

Answer 4

Pharmacists are lifelong learners, engaging in continuing education to stay current with changes in pharmaceutical science, health policy, and research.

Question 5

Managed Care Pharmacists’ Responsibilities:

Answer 5

Responsible for developing and using a broad range of clinical and quality-oriented drug management services.

Involved in population health management and provide patient-centered care as integral members of the healthcare team.

Question 6

Patient Safety

Answer 6

Pharmacists in managed care play a crucial role in ensuring the safety of patients. This involves monitoring and assessing the use of medications to prevent adverse effects, interactions, or other potential risks to patients’ well-being.

Question 7

Conduct Drug Utilization Review (DUR):

Answer 7

Drug Utilization Review is a process where pharmacists systematically evaluate and analyze the prescribing, dispensing, and use of medications. This review helps identify opportunities to optimize therapy, prevent adverse effects, and ensure cost-effective medication use.

Question 8

Serve on Pharmacy and Therapeutics (P&T) Committees:

Answer 8

P&T Committees are responsible for formulating and updating the drug formulary.

Pharmacists contribute their expertise in these committees, participating in decisions about which medications to include in the formulary based on factors like safety, efficacy, and cost-effectiveness.

Question 9

Design and Run Medication Therapy Management (MTM) Programs:

Answer 9

MTM programs are designed to optimize therapeutic outcomes for patients. Pharmacists create and implement these programs to ensure that patients are using their medications effectively, understand their treatment plans, and are achieving desired health outcomes.

Question 10

Develop Quality Assurance Programs:

Answer 10

Quality assurance programs in pharmacy involve implementing processes and protocols to maintain and improve the quality of pharmaceutical care. This may include regular reviews, audits, and assessments to ensure that pharmacy services meet established standards.

Question 11

Create Programs to Detect Fraud, Waste, and Abuse of Medications:

Answer 11

Pharmacists contribute to the development of programs aimed at identifying and preventing fraud, waste, and abuse in the use of medications. This may involve monitoring prescription patterns, detecting inappropriate use, and implementing strategies to mitigate these issues.

Question 12

Create Programs to Detect Fraud, Waste, and Abuse of Medications:

Answer 12

Pharmacists contribute to the development of programs aimed at identifying and preventing fraud, waste, and abuse in the use of medications. This may involve monitoring prescription patterns, detecting inappropriate use, and implementing strategies to mitigate these issues.

Question 13

Design Drug Benefit Plans:

Answer 13

Pharmacists are involved in designing drug benefit plans for patients. This includes determining which medications are covered, setting copay structures, and ensuring that the benefit plan aligns with the healthcare goals of the patient and the organization.

Question 14

Help Clients Evaluate and Improve Their Pharmacy Benefit:

Answer 14

Pharmacists provide guidance to clients, which may include health plans, employers, or other organizations, in evaluating and enhancing their pharmacy benefit programs. This involves assessing the effectiveness, efficiency, and cost-effectiveness of the pharmacy benefit and recommending improvements as needed.

Question 15

P&T Committees & Formularies

Answer 15

P&T Committees review and assess medication formularies, which are lists of medications covered by a health plan. The goal is to ensure that the formulary promotes safety, effectiveness, and affordability. This involves selecting medications that provide optimal therapeutic outcomes while managing costs.

Question 16

Therapeutic Classes & P&T Committees

Answer 16

P&T Committees also focus on therapeutic classes, which are groups of medications targeting specific health conditions. They aim to update and implement best practices within these classes, ensuring that the chosen medications are aligned with the latest evidence-based guidelines and treatment protocols.

Question 17

Peer-Reviewed Literature and Clinical Trials:

Answer 17

P&T Committees rely on peer-reviewed literature and data from clinical trials. By staying abreast of the latest scientific research, committees can make informed decisions about the inclusion or exclusion of specific medications in the formulary. This ensures that the chosen drugs have demonstrated efficacy and safety.

Question 18

Collaboration Among Healthcare Professionals: P&T Committees

Answer 18

Collaboration is key in the formulary management process. Healthcare professionals, including prescribers and pharmacists, work together to enhance access to safe, cost-effective, and evidence-based medication therapy. This collaborative approach ensures that decisions are well-informed and consider diverse perspectives.

Question 19

Focus on High-Cost Specialty and Biologics:

Answer 19

With the increasing focus on high-cost specialty medications and biologics, formulary management becomes even more critical. P&T Committees navigate the challenges of incorporating these innovative but costly treatments, balancing the need for patient access with cost-effectiveness.

Question 20

Evaluation of Clinical and Medical Literature:

Answer 20

Formulary systems leverage the expertise of P&T Committees to evaluate clinical and medical literature. When selecting preferred medications for different diseases and conditions, committees consider the latest evidence to tailor the formulary to the unique needs of the plan’s patient population.

Question 21

Drug Tier Assignment:

Answer 21

Pharmacy & Therapeutics (P&T) Committees assign medications into different “drug tiers” based on a comprehensive evaluation of clinical and cost information. This process helps structure the formulary in a way that aligns with the goals of safety, efficacy, and affordability.

Question 22

Factors Influencing Tier Assignment:

Answer 22

Medications are placed in tiers considering factors such as usage patterns, overall cost, and, significantly, effectiveness. The goal is to categorize drugs in a manner that reflects their clinical impact and financial implications.

Question 23

Tier Structure and Patient Accessibility:

Answer 23

Drug tiers are structured to influence patient access and out-of-pocket costs. Tier 1 drugs, often generic or preferred brands, are more accessible to patients with lower out-of-pocket costs. As you move to higher tiers, patients typically face increased copay responsibilities due to the higher cost of medications.

Question 24

State Laws and Tier Requirements:

Answer 24

Some states have enacted laws that mandate specific drugs to be placed on certain tiers. This regulatory approach aims to ensure fairness, consistency, and transparency in the placement of medications within formularies, preventing arbitrary or discriminatory practices.

Question 25

Cost Determination by Manufacturer and Distributor

Answer 25

The cost of a drug is primarily determined by the manufacturer and the distributor. Health plans, payers, pharmacy benefit management (PBM) plans, and employers don’t directly set the cost of the drug. Instead, they negotiate with manufacturers and distributors to establish pricing agreements.

Question 26

Prospective Drug Utilization Review (DUR):

Answer 26

Purpose: This type of review occurs before a patient receives a new medication and involves evaluating medical and medication therapy information.

Key Focus Areas:

Identification of drug-drug and drug-disease interactions.

Assessment of dosing appropriateness.

Checking for medication allergies.

Ensuring clarity and completeness of medication directions.

Outcome: Pharmacists can identify and resolve potential issues before the patient takes the medication, ensuring safety and efficacy.

Question 27

Concurrent Drug Utilization Review (DUR):

Answer 27

Purpose: This review happens during the treatment process, evaluating the patient’s ongoing therapy.
Key Focus Areas:
Monitoring over or underutilization of medication.
Assessing excessive or insufficient dosing.
Identifying potential drug-drug interactions.

Outcome: Allows for real-time adjustments to the patient’s therapy if needed, ensuring that the treatment aligns with the best practices.

Question 28

Retrospective Drug Utilization Review (DUR):

Answer 28

Purpose: This review involves evaluating medications that have already been administered to reveal trends in prescribing, administering, and dispensing.

Key Focus Areas:
Assessment of appropriate use of generic medications.

Identifying patterns of inappropriate use of medications.

Ensuring medication use aligns with evidence-based guidelines.

Outcome: Provides insights into past medication practices, aiding prescribers in improving patient care either individually or as part of a patient population.

Question 29

Tim’s asthma is poorly controlled, and he frequently uses his inhaler.

What type of DUR would it be if a step was taken by the Pharmacist at this point?

Answer 29

The pharmacist conducts a concurrent DUR and observes that Tim is prescribed only an as-needed inhaler.
Based on evidence-based guidelines, the pharmacist recommends to the prescriber, and Tim is subsequently prescribed a maintenance asthma medication.

Question 30

John has been prescribed a new medication for his hypertension. Before John receives the medication from the pharmacy, the pharmacist performs a DUR. During this review, the pharmacist checks John’s medical history, current medications, and any known allergies.

What type of DUR is this?

Answer 30

prospective DUR

The focus is on identifying potential interactions with other drugs John is taking and ensuring the prescribed dosage is appropriate.

Question 31

Over the past six months, a healthcare organization conducts a DUR to assess the utilization of a specific antidepressant medication within their patient population.

What type of DUR is this?

Answer 31

Retrospective DUR:

The goal is to analyze trends, identify any patterns of inappropriate use, and evaluate adherence to evidence-based guidelines.

Question 32

EPA

Answer 32

Electronic Prior Authorization

Question 33

What is an EPA?

Answer 33

ePA Defined: Electronic Prior Authorization (ePA) is an automated version of the PA process, offering real-time responses to authorization requests.

Question 34

What is the purpose of a PA?

Answer 34

: ePA serves as an additional step to guarantee that a prescribed medication is medically necessary, even when there may be clinically effective and less expensive alternatives available.

Question 35

NCPDP SCRIPT standard-based ePA

Answer 35

Refers to the use of the National Council for Prescription Drug Programs (NCPDP) SCRIPT standard for electronic prior authorization (ePA) processes.

Question 36

What is step therapy?

Answer 36

Step Therapy is a utilization management strategy in healthcare where patients are required to try a proven, clinically effective prescription before moving on to a medication with less evidence of effectiveness or a higher cost.

Question 37

Are most prescriptions subject to step therapy programs?

Answer 37

The majority of prescriptions are not subject to step therapy programs; however, for certain conditions or medications, this approach may be implemented.

Question 38

Managed Care Pharmacists’ Role in Step Therapy

Answer 38

Managed care pharmacists play a vital role in determining if a specific medication is preferred based on criteria such as its effectiveness, safety, and cost.

Question 39

Patient Options in Step Therapy:

Answer 39

Use the preferred medication: covered by insurance

Alternative medication: Pay out of pocket

Question 40

Prescriber Involvement:

Answer 40

Prescribers can contribute to the process by providing additional information about the patient’s medical history. This information may influence the determination of whether the patient continues with the preferred medication or explores alternatives.

Question 41

Benefits of Step Therapy:

Answer 41

Cost Savings: Step therapy is designed to control healthcare costs by encouraging the use of cost-effective medications first.

Effectiveness Assessment: The stepwise approach allows for an assessment of the effectiveness of the preferred medication before exploring alternatives.

Patient-Centric Approach: While following a structured approach, step therapy allows flexibility by considering the patient’s unique circumstances and medical history.

Question 42

Medication Therapy Management (MTM):

Answer 42

MTM services aim to identify and address issues related to medication, ensuring proper usage and management.

Question 43

MTM Benefits for Patients:

Answer 43

Beneficial for patients managing several medications for multiple health conditions.

Particularly advantageous for patients on medications that demand close monitoring due to their nature or potential side effects.

Helpful during transitions, such as moving from the hospital to home or transitioning to a long-term care facility.

Valuable for patients obtaining medications from different pharmacies.

Question 44

Patient-Centric Care & MTMs

Answer 44

MTM enhances patient understanding, promotes safe medication use, and provides targeted support based on individual needs.

Addresses potential problems, improving overall medication management for enhanced health outcomes.

Question 45

Sarah manages diabetes, hypertension, and recently transitioned from the hospital to home. Would she benefit from MTM?

Answer 45

Yes

Sarah qualifies for MTM due to her complex medication regimen and recent transition.

MTM identifies potential medication-related issues, ensures Sarah understands proper medication usage, and helps coordinate her care during the transition.

Question 46

Mary, a single mother in her mid-30s, manages mild seasonal allergies. She takes her medication as needed. Would she benefit from MTM?

Answer 46

No,

Mary’s health condition is uncomplicated, and her medication regimen is straightforward.

There are no recent changes in her health or transitions between healthcare settings.

Mary’s medication is easily accessible over-the-counter, and she hasn’t experienced any issues with her current management approach.

Question 47

Mail order pharmacy

Answer 47

Supports individuals with chronic conditions by ensuring timely medication delivery, preventing gaps between prescription refills.

Question 48

Peter, a working individual with a busy schedule, is prescribed new medications for a chronic condition. Peter faces difficulty finding time to visit the pharmacy due to his job schedule, leading to delayed prescription pickups.

Would he benefit from mail-order?

Answer 48

Yes

Peter opts for mail service pharmacy, receiving medications automatically every three months.

Peter no longer misses doses, as his medications are delivered to his door.

Cost savings on copays are achieved through the mail service option.

Peter maintains the flexibility to use his community pharmacy for other prescriptions and retail needs.

Question 49

Cost savings on copays are achieved through the mail service option.

How?

Answer 49

Bulk Purchasing Advantage:

Mail service pharmacies may purchase medications in larger quantities, securing potential discounts from manufacturers or wholesalers.
These cost savings can be passed on to patients in the form of reduced copays.

Lower Administrative Costs:

Mail service pharmacies may have lower operational costs compared to traditional brick-and-mortar pharmacies.

Reduced overhead can contribute to overall cost savings, which may be reflected in lower copays for patients.