Sec A Drugs

Question 1

Services provided by medication therapy management (MTM) programs

Answer 1

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 communcating essential information to the patient’s other primary care providers
7. Providing verbal education and training designed to enhance patient understanding and appropriate use of medications
8. Providing information, support services, and resources to enhance patient adherence to drug regimens
9. Coordinating and integrating MTM services with other health care management services

Question 2

Formulary guidelines for Part D plans

Answer 2

1. There are 146 therapeutic categories that must be included
2. If a generic is availble, it must be included
3. If the pharmacy dispenses a brand name drug, it must inform the patient of any differential between the price of the brand and the lowest-priced generic of that drug
4. Preferred drug rebates must go to the payer to decrease the cost of the program
5. At least 2 drugs must be included in each “key drug type” category
6. The formular must include prior authorizations, step therapy, generic drug requirements, and preferred brand name drugs
7. Substantially all drugs in the following classes must be included: antidepressants, antipsychotics, anticonvulsants, anticancer, immunosuppressants, and HIV/AIDS medications

Question 3

Definition and types of drug formularies

Answer 3

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

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

Question 4

Categories of drugs that are typically excluded on prescription drug plans

Answer 4

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

Question 5

Metrics for measuring financial performance of pharmacy programs

Answer 5

1. Various cost parameters (e.g., program expenses, billed and paid claims, and copayments)
2. Prescription utilization and trends
3. Administrative and claims processing fees
4. Prescription discount or rebate
5. Generic dispensingand 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 formular prior authorization exception requests and approvals
9. HEDIS measures related to pharmacy
10. Drug utilization review exception reports

Question 6

Future trends that will affect pharmacy program management

Answer 6

1. The patent loss of approximately $90 billion of brand name drugs, resulting in low-cost trends
2. A simultaneous increase in the number of specialty drugs approved by the FDA
3. Due to the high cost of specialty drugs, health plans will integrate some portion of their medical and pharamacy management
4. By 2019, the number of beneficiaries in Medicare and Medicaid will grow by 30%
5. Due to the ACA and CMS policy, there will be several initiatives to measure and promote practice patterns and risk-sharing contracts that improve outcomes and the quality of care
6. New technologies will support accountable care organizations and patient-centered medical homes
7. Health plans and pharmacy benefit managers (PBMs) will likely implement greater restrictions on their formularies

Question 7

Services typically offered by PBMs

Answer 7

1. Claims processing and management reports
2. Community retail pharmacy provider network
3. Home delivery (mail service) prescriptions
4. Specialty pharmacy distributions 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 managemnt (MTM)
9. Other customized services requested by plan sponsors

Question 8

Components of prescription drug program management

Answer 8

1. Certificate or evidence of coverage - to legally enforce the benefit design
2. Pharmacy benefit design - plan sponsor-specific benefit management strategies
3. Drug formulary - list of covered drugs and access rules
4. Pharmacy provider network - drug distribution channels to provide member access to covered drugs
5. Information technology - claims processing and decision support systems to optimize program performance
6. DUR, MTM, and clinical programs - resources to support patients and maximize outcomes

Question 9

Types of interventions conducted by pharmacists

Answer 9

1. Drug utilization review - these programs manage price by substituting lower-cost alternatives for higher-cost drugs, and they manage utilization by requiring prior authorization for certain drugs
2. Medication Therapy Management (MTM) - Part D plans are required to have MTM programs, which aim to improve medication use and reduce adverse events for beneficiaries that have multiple chronic conditions, are taking multiple Part D drugs, and are likely to incur annual costs of at least $4k for all covered Part D drugs
3. Pharmacist-delivered care management programs - pharmacists can collaborate with PCPs on medication optimization and medication safety. These programs often focus on drug adherence, which is measured in one of two ways:
   a) Medication possession ratio = # of days supply in the patient’s possession / # of days during the measurement period during which the patient could have had the drug
   b) Proportion of days covered = # of days of coverage / total # of days in the measurement period

Question 10

Types of drug utilization review programs

Answer 10

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