Prescription Drug Plans pt 2 Flashcards Preview

Directing Benefits Programs > Prescription Drug Plans pt 2 > Flashcards

Flashcards in Prescription Drug Plans pt 2 Deck (22)
Loading flashcards...

What is a formulary

A list of drugs preferred by a health plan or PBM


Who is a formulary designed by

Pharmacy and therapeutics (P&T) committee.


Who composes a P&T committee

Physicians, pharmacists and nurses who may be complemented by pharmacoeconomists, ethicists, the lay public and plan administration


Why is the use of a formulary common

Because they are very effective at moving patients to lower cost drugs and maximizing rebate potentials


What is a drawback of a formulary

Constant communication to physicians and patients that is necessary regarding the current list of preferred products. When a PBM changes its formulary and does not communicate those changes, members may become dissatisfied.


This type of formulary allows plan enrollees and covered prescription drug prescribed for them

Open formulary


This type of formulary encourages patients to use the preferred or formulary drugs in return for reduced payment

Preferred formulary


This type of formulary will not cover nonformulary drugs. Typically found in hospital settings and tightly managed HMO programs

Closed formularies


What nonformulary cost-management tools are available to contain prescription drug costs?

1. Network management, better discounts with retail and mail order programs
2. Designing plans that meet the objectives of the overall benefit programs
3. Quantity limits and maximum dollar limits
4. Step-therapy programs
5. Prospective review of new drugs and early policy determination
6. Clinical management
7. Other DUR programs such as concurrent and prospective programs
8. Quality data management that provides early intervention reporting


Developed to measure and manage all health care outcomes and costs associated with a particular disease

Disease state management (DSM)


Describe two main types of DSM programs

Medical Model
Therapy Directed Model


Follow up on patients with select diseases to ensure that the patients are scheduling physician appointments, receiving appropriate tests and procedures and understand the importance of taking their medications

Medical Model


Administered by PBMs, pharmaceutical manufacturers, health plans and disease management companies

Therapy directed model


Approach to medical decision making that emphasizes scientific evidence and statistical methods for evaluating outcomes and risk of treatments. Response to arrive at objective decisions in the face of mass media advertising, direct to consumer advertising or drugs, and the promotions of pharm and device manufacturers.

Evidence based medicine


How does a network system in a prescription drug program operate?

Employees must have their prescriptions filled by a network pharmacy, except in emergencies.

Pharmacies join networks and provide services at reduced rates in exchange for volume business.

Allows PBMs to control costs and quality


What is a PBM

Entity that administers managed pharmacy programs. Application of programs, services and techniques designed to control costs associated with the delivery of pharmaceutical care


What are the benefits of a PBM

Streamline the prescribing and dispensing process through online and real time claims adjudication

Maintain retail network of pharmacies and mail order options that in turn offer discounts

Offers limited DUR online at point of sale

Provides data and reporting regarding drug use

Controls cost of prescriptions


Summarize the common services that PBMs provide

Claims processing
Account management and support
Retail network of pharmacies
Mail order
Communication to patients
Formulary development
Some drug utilization management
Industry trends


How can PBM prices vary

Age of enrollees
Type of industry
Overall health of beneficiaries
Size of group covered
Elements plan sponsor wants to include


How do PBMs generate profit

Admin fees
Retaining rebate administrative fees negotiated with manufacturers
Mail service
Securing Discounts
Retaining pharmacy spread
Retaining MAC list payments
Reducing payments to pharmacies based on certain package sizes


Discuss the features of rebates under prescription drug programs

A rebate is an agreement between a PBM and a drug manufacturer to secure significant reductions in the cost of prescription drugs.

* Growth in rebates paid to payers has paralleled the rise of pharmacy benefit inflation and the advent of multi tiered copay designs


What factors should an employer consider in the selection process of a PBM

Claim administration
Service delivery
Administration oversight
Transparency or pricing