Test 3 Overview of the Prescription Benefit Flashcards

1
Q

Define the pharmacy benefit manager (PBM)

A
  • 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
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2
Q

What are services that a PBM provide?

A
  • 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
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3
Q

goals of PBM

A
  • manage supply cost of pharmaceuticals

- manage utilization demand of pharmaceuticals

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4
Q

Reasons for Aggressive Management

A
  • Prescription costs can increase rapidly
  • Prescription benefits are highly utilized
  • Pharmaceuticals have a well known structure for management
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5
Q

List the major components of a PBM

A
  • Legal basis
  • Information systems
  • Distribution channels
  • Pharmacy and therapeutics committee
  • Drug formulary
  • Pharmaceutical rebate contracts
  • Clinical and disease management services
  • Quality and performance oversight
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6
Q

Discuss the legal basis of a PBM

A
  • 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
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7
Q

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

A

– 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

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8
Q

pharmacy claim adjudication process

A
  • 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
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9
Q

Describe the common types of pharmacies used in provider networks

A

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

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10
Q

advantages of retail pharmacy network inclusion

A

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

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11
Q

disadvantages of retail pharmacy network inclusion

A

– Members may not choose lowest priced pharmacy

– Less control of formulary products

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12
Q

advantages of mail service pharmacy

A

– 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

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13
Q

disadvantages of mail service pharmacy

A
– Lack of personal contact 
– Increased waste 
– Advance request needed 
– Lost prescriptions 
– Cost savings not always passed on to sponsors or members
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14
Q

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

A

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

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15
Q

What does the P&T Committee do?

A
  • 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
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16
Q

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

A

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