powerpoint Flashcards
who IS recognized as a provider in part B of the social security act?
physicians, PA’s, NP’s, qualified psychologists, clinical social workers, certified nurse midwives, and certified registered nurse anesthetics
the _____________ designates communites with unmet health care need as ______, ____, and _____
the dept of health and HRSA (health resources and services administration)
MUAS – medically underserved areas
MUPS – medically underserved populations
HPSAS – health professional shortage areas
define MUAS (medically underserved areas)
geographic areas that have too few primary care providers, high infant mortality, high poverty, and a high elderly population
define MUPS (medically underserved populations)
takes into account the same factors used to identify MUAs, but focuses on specific population groups with the same characteristicsd
define HPSA
health professional shortage areas – areas with shortages of primary medical care, dental, or mental health providers
BPS is a division of______ it was established in _____
BPS is a division of the APHA
established in 1976
who provides speciality certification for pharmacists?
BPS
how many pharmacy specialties are there?
14
who are the “big 3” wholesalers
ABC (amerisourceBergen corp)
cardinal health (CAH)
mckesson corporation
name the 14 pharmacy specialties, recognized by BPS
- ambulatory care
- cardiology
- compounded sterile preparations
- critical care
- emergency medicine
- geriatric
- infectious disease
- nuclear
- nutrition support
- oncology
- pediatric
- pharmacotherapy
- psychiatric
- solid organ transplantation
give the definition of a PBM
companies that manage prescription drug benefits on behalf of health insurers, medicare part D drug plans, large employers, and other payers
another def: “a third party administrator of prescription drug programs for commercial health plans, self-insured employer plans, medicare part D plans, the federal employees health benefits program, and state government employee plans
PBMs are primarily responsible for ____, ____, ____, and ____
developing and maintaining the formulary, contracting with pharmacies, negotiating discounts and rebates with drug manufacturers, and processing and paying prescription drug claims
what 3 entities does a PBM negotiate with ? explain
pharmacy, insurance company, and manufacturer
the insurance company pays the PBM to manage its drug costs and get rebates from the manufacturer (PBM gets some of the rebate)
PBM negotiates prices with the manufacturer. manufacturer pays rebates to the PBM in exchange for the PBM making them the preferred placement on a plan’s formulary
PBM negotiates with the pharmacy over reimbursement for drugs and dispensing fees
who does the pharmacy negotiate with?
the PBM and the manufacturer
who sets the copays, coinsurance, and determines out of pocket costs?
the PBM
name 5 ways in which PBMS help to cut drug costs
- mail order medications and creating networks of cost effective and affordable pharmacies
- encourage use of generics
- manage high cost specialty meds
- reduce waste and improve adherence
- compliance building, utilization management, disease management, and DUR programs
what is the AWP
average wholesale price
average price paid by a retailer to buy a drug from the wholesaler
a BENCHMARK number for pricing and reimbursement of prescription drugs. not a true representation. usually inflated around 20%
“LIST PRICE OR STICKER PRICE” elevated price. rarely paid
managed care pharmacists serve on ____ committees
p & t committees (pharmacy and therapeutics)
what is the purpose of a formulary
to support a healthcare organizations cost and quality of care objectives
what is tier 1-4 of formularies
tier 1 - generics
tier 2 - preferred
tier 3 - non-preferred
tier 4 - specialties
what are the 3 types of DUR? explain them
prospective — evaluation of a patients drug therapy before the medication is disepensed
concurrent — ongoing monitoring of drug therapy during the course of treatment
retrospective — review of drug therapy after the patient received the medication
what is the estimated cost of drug development? break it down
2.6 billion
1.4 billion for out of pocket costs
1.2 billion for time costs
what is an NDC
explain the numbers
national drug code.
10 digit or 11 digit 3 segment number. a universal product identifier for human drugs in the US
1st set of numbers identifies the LABELER (manufacturer, repackager, or distributor)
2nd set is the product code — identifies strength, dosage form, and formulation of the drug
3rd set — package code. identifies package size and types
what is medwatch
FDA program that collects reports of safety alerts for products regulated by the FDA
