Rx Benefits in Managed Care

Question 1

Future trends that will affect Rx program management (7)

Answer 1

1. ) Patent loss of approx $90B of brand name drugs results in low-cost trends
2. ) Simultaneous increase in number of specialty drugs approved by FDA
3. ) Due to high cost of specialty drugs, health plans will integrate some portion of their medical and rx management
4. ) By 2019, Medicare & Medicaid members will grow by 30%
5. ) Due to ACA and CMS policy, there will be several initiatives to measure and promote practice patterns and risk-sharing contracts that improve outcomes and quality of care
6. ) New technologies will support ACO and patient-centered medical homes
7. ) Health plans and PBMs will likely implement greater restrictions on their formularies

Question 2

Services offered by PBMs (9)

Answer 2

1. ) Claims processing and management reports
2. ) Community retail pharmacy provider network
3. ) Home delivery (mail services) prescriptions
4. ) Specialty pharmacy distribution services
5. ) Drug formulary development and management
6. ) Pharmaceutical manufacturer contracting
7. ) Customized pharmacy benefit design development and administration
8. ) Clinical pharmacy programs, such as drug utilization review (DUR) and medication therapy management (MTM)
9. ) Other customized services requested by plan sponsors

Question 3

Categories of drugs that are typically excluded on Rx plans (4)

Answer 3

1. ) Experimental or investigational drugs (not approved by FDA)
2. ) FDA-approved drugs when prescribed for unapproved indications (“off label” use)
3. ) Drugs used for cosmetic purposes or specific purposes such as smoking cessation or inferitlity
4. ) Over the counter drugs other than insulin

Question 4

Drug formulary definition

Answer 4

A continuously updated list of covered drugs and access rules (such as tier structure and dispensing limits). It should be supported by current evidence-based medicine and the judgement of physicians, pharmacists, and other experts.

Question 5

Drug formulary types (2)

Answer 5

1. ) Open formulary - generally covers most drugs (except cosmetic or OTC drugs)
2. ) Closed formulary - doesn’t cover as many drugs. Drugs not included in the formulary are not eligible for payment except by an approved medical exception.

Question 6

Types of drug utilization review programs (3)

Answer 6

1. ) Prospective- identify & resolve problems before rx is dispensed. Services as excellent member-teaching opportunity for pharmacists.
2. ) Concurrent - performed at the point-of-prescribing. Pharmacists are provided clinical & benefit design edits that provide an alert for potential clinical conflicts to evaluate before product is dispensed.
3. ) Retrospective - performed after prescription is dispensed. It could include review of high cost outliers.

Question 7

Formulary guidelines for Part D plans (7)

Answer 7

1. ) Must include 146 therapeutic categories
2. ) If a generic is available, it must be included
3. ) If pharmacy dispenses a brand name drug, it must inform patient of price diff of brand and lowest priced generic of that drug
4. ) Drug rebates must be passed on to payer to decrease program cost
5. ) Each “key drug type” category must have at least 2 drugs
6. ) Formulary must include prior authorizations, step therapy, generic drug requirements, and preferred brand name drug
7. ) Substantially all drugs in the following classes must be included: antidepressants, antipsychotics, anticonvulsants, anticancer, immunosuppressants, and HIV/AIDs medications

Question 8

Services provided by medication therapy management (MTM) programs (9)

Answer 8

1. ) Performing or obtaining necessary assessments of the patient’s health status
2. ) Formulating a medication treatment plan
3. ) Selecting, initiating, modifying, or administering medication therapy
4. ) Monitoring and evaluating the patient’s response to therapy
5. ) Performing a comprehensive medication review to identify, resolve, and prevent medication-related problems
6. ) Documenting the care delivered and communicating essential information to the patient’s other primary care providers
7. ) Providing verbal education and training designed to enhance patient understanding
8. ) Providing information, support services, and resources to enhance patient adherence
9. ) Coordinating and integrating MTM services with other health care services

Question 9

Metrics for measuring financial performance of pharmacy programs (10)

Answer 9

1. ) Various cost parameters (e.g. program expenses, billed and paid claims, and copayments)
2. ) Prescription utilization and trends
3. ) Admin and claim processing fees
4. ) Rx discount or rebate
5. ) Generic dispensing and conversion rates and missed generic substitution opportunities
6. ) Drug formulary conformance rate
7. ) Patient satisfaction and member complaints related to the pharmacy program
8. ) Number of drug formulary prior authorization exception requests and approvals
9. ) HEDIS measures related to pharmacy
10. ) Drug utilization review exception reports

Question 10

Drug Utilization Review Targets (5)

Answer 10

1. ) Adherence
2. ) Situations in which drug should not be used
3. ) Drug interaction
4. ) Drug formulary interaction
5. ) Incorrect dossage

Question 11

Skilled Nursing Facility Impact (3)

Answer 11

1. ) Part D plans must contract with any willing LTC pharmacy to ensure convenient access to LTC pharmacies
2. ) Part D plan may require participating LTC pharmacies to offer a portfolio of services (such as delivery of meds, access to urgent meds)
3. ) Utlimately, the nursing facility is responsible for all aspects of care for residents, including drugs.

Question 12

Pharma Program Quality Measure Categories (3)

Answer 12

1. ) Administrative measures - focus on IP pharmacy operations
2. ) Operational measures - focus on computer-generated information and customer service requests
3. ) Integrated health quality measures - focus on patient care from a medical perspective and include pharmacy measures for specific diseases.