Pharmacy Claim Costs Flashcards
1
Q
Pharmacy Claim Costs
Normalized Script Counts
A
Normalized to a monthly basis for scripts for multiple months
2
Q
Pharmacy Claim Costs
Determine Net Plan Liability
A
- Project expected claim costs
- Apply member cost-sharing
- Apply rebates
3
Q
Pharmacy Claim Costs
Items that Impact Allowed Cost Trend
A
- Unit cost change
- Utilization change
- Mix change = change in type of drugs used
4
Q
Pharmacy Claim Costs
Important Rating Factors
A
- Demographics
- Area
- Benefit Design
- Formulary & Formulary Management Programs
- Contracting (Discounts and Dispensing)
- Other (UM, generic dispensing rates, mail order utilization)
5
Q
Pharmacy Claim Costs
Expected Net Plan Liability
A
= Projected Allowed - Mbr Cost Sharing - Rebates
6
Q
Pharmacy Claim Costs
Analytic Pricing Considerations
A
- Timing of Rebates (quarterly, semi-annual)
- Credibility
- Integrated Plans (Med + Rx)
- Fixed Cost Leveraging
7
Q
Pharmacy Claim Costs
Goals of Formulary Design
A
- Adequate Coverage
- Marketability
- Cost control
8
Q
Pharmacy Claim Costs
Valuing Tier Changes for Formulary
A
- Project market share utilization change
- Account for changes to all drugs in therapeutic class
9
Q
Pharmacy Claim Costs
Price Protection (definition, purpose)
A
Agreement between manufacturer and health plan where price for given drug will not exceed threshold
- If threshold is exceeded, manufacturer pays health plan an additional rebate
- Purpose = control increases in drug prices
