Test 3 Overview of the Prescription Benefit

Question 1

Define the pharmacy benefit manager (PBM)

Answer 1

• organization that specializes in development and management of comprehensive and cost-effective prescription drug benefits
• may be stand-alone or part of overall medical plan

Question 2

What are services that a PBM provide?

Answer 2

• Pharmacy distribution networks
• Drug formulary development and management
• P&T committee support services
• Pharmaceutical manufacturer contracting
• Physician and member communications
• Member service help line
• Pharmacy benefit website development and management
• Clinical pharmacy services
• Claims processing and drug utilization report generation

Question 3

goals of PBM

Answer 3

• manage supply cost of pharmaceuticals

- manage utilization demand of pharmaceuticals

Question 4

Reasons for Aggressive Management

Answer 4

• Prescription costs can increase rapidly
• Prescription benefits are highly utilized
• Pharmaceuticals have a well known structure for management

Question 5

List the major components of a PBM

Answer 5

• Legal basis
• Information systems
• Distribution channels
• Pharmacy and therapeutics committee
• Drug formulary
• Pharmaceutical rebate contracts
• Clinical and disease management services
• Quality and performance oversight

Question 6

Discuss the legal basis of a PBM

Answer 6

• know that there are federal and state laws and regulations govern many aspects of health care
• PBM is a company not a health care provider

Question 7

PBM is a company. List some aspects associated with that.

Answer 7

– They are a benefit provider – a payer
– Contract with healthcare professionals
– Pathways for payments outside of defined benefit (appeals)
– Patients can purchase care outside of coverage

Question 8

pharmacy claim adjudication process

Answer 8

• uses National Council for Prescription Drug Programs (NCPDP)
• member takes prescription and ID card to pharmacy
• pharmacy submit online claim to PBM
• PBM verifies eligibility and determines benefit
• PBM delivers online response to store
• Pharmacy fills prescription and collects copayment
• member receives prescription drug

Question 9

Describe the common types of pharmacies used in provider networks

Answer 9

– Community pharmacy
– Mail-order pharmacy
– Specialty pharmacy
– Other types

Question 10

advantages of retail pharmacy network inclusion

Answer 10

– Large number of participating pharmacies ensures patient access
– Acute care access available for members
– Competing pharmacies decrease costs

Question 11

disadvantages of retail pharmacy network inclusion

Answer 11

– Members may not choose lowest priced pharmacy

– Less control of formulary products

Question 12

advantages of mail service pharmacy

Answer 12

– Better able to set price and contain costs
– Increased volume if single provider
– Possible increased use of technology and error minimization
– Delivery convenience
– Deeper manufacturer discounts
– Toll-free drug information line, refill reminders, educational material

Question 13

disadvantages of mail service pharmacy

Answer 13

– Lack of personal contact 
– Increased waste 
– Advance request needed 
– Lost prescriptions 
– Cost savings not always passed on to sponsors or members

Question 14

What is a Pharmacy and Therapeutics (P&T) Committee?

Answer 14

Policy-recommending body to an organization regarding the therapeutic use of drugs

Question 15

What does the P&T Committee do?

Answer 15

• Develop and maintain the formulary system for the managed care plan
• Objectively appraise, evaluate and select products for formulary inclusion
• Interact with quality assurance or medical utilization committee

Question 16

Why does a P&T committee reviews drugs for efficacy and safety even though the drugs have FDA approval?

Answer 16

with FDA approval, there isnt’t:

• comparison to other products
• efficacy heirarchy
• side effect or safety comparison
• cost-effectiveness comparison
• costs included in FDA approvals