Fundamentals of Managed Care Pharmacy Certificate Program 2nd Edition - Professional Version

This video clip is an excerpt from the module titled, "Trading Partners and Flow of Money in Managed Care" .

The Fundamentals of Managed Care Pharmacy Certificate Program 2nd Edition provides an updated comprehensive introduction to basic concepts in managed care pharmacy. With the help of key thought-leaders and experts, learners will explore key aspects of managed care pharmacy, including its evolution, pharmacy benefit management tools and strategies, specialty pharmacy, Medicaid and Medicare, quality measures, and much more.

Target Audience

This program is designed for pharmacists, pharmacy residents, managed care/managed markets team members, and other individuals who are interested in expanding their understanding of managed prescription drug benefits.

Activity Fee:      AMCP Member:  $399       Non-Member: $499

Evolution and Principles of Managed Care

ACPEUAN #: 0233-0000-19-001-H04-P

Release Date:  February 1, 2019

Expiration Date:  February 1, 2022

Activity Type:  Knowledge-based  

Contact Hours:  0.75 contact hours

Activity Overview

Understanding the evolution of managed care pharmacy is important in order to understand the current marketplace. This module delves into the history of managed care and its progression to current practices, the different care delivery models and how each one works to provide patient access to care. This includes discussions of health maintenance organizations (HMOs), preferred provider organizations (PPOs), point-of-service plans (POS’s), integrated delivery networks (IDNs), high deductible health plans (HDHPs), carve outs, and a la carte benefit models.

Learning Objectives

At the completion of this activity, participants should be able to:

  • Outline the evolution of managed care in the United States.
  • Describe the different types of delivery models and how each impacts patient health care access.
  •  Distinguish between medical and pharmacy benefits and what services fall under each benefit type.
Pharmacy Benefit Management Tools

ACPE UAN #: 0233-0000-19-002-H04-P

Release Date:  February 1, 2019

Expiration Date:  February 1, 2022

Activity Type:  Knowledge-based  

Contact Hours:  0.75 contact hours

Activity Overview

How do pharmacy benefits meet the demands of balancing safety, effectiveness and accessibility of drug products while also ensuring that the most cost-effective treatment options are used appropriately in the service of optimal health outcomes? This module discusses various management strategies and tools used in the management of pharmacy benefits.

Learning Objectives

At the completion of this activity, participants should be able to:

  •  Discuss common strategies used to manage the cost of medications and demand for medications in a pharmacy benefit
  • Recognize how various drug cost and utilization management strategies can be combined to design a customized pharmacy benefit.  

Behind the Scenes: Getting Medications to Patients through the Pharmacy Benefit

ACPE UAN #: 0233-0000-19-003-H04-P

Release Date:  February 1, 2019

Expiration Date:  February 1, 2022

Activity Type:  Knowledge-based  

Contact Hours:  0.75 contact hours

Activity Overview

This module explores the behind the scenes coverage, prescribing, claims and adjudication processes. Participants will learn about the invisible steps and data exchange that culminate into a filled prescription, ready for pick up. Differences between traditional and electronic prescribing, use of claims analysis and edits, and importance of data exchange and reporting are some of the concepts discussed in this module.

Learning Objectives

At the completion of this activity, participants should be able to:

  • Summarize the difference between traditional paper prescribing and electronic prescribing.
  • List the steps involved in adjudicating a prescription drug claim.

Developing and Managing the Drug Formulary

ACPE UAN #: 0233-0000-19-004-H04-P

Release Date:  February 1, 2019

Expiration Date:  February 1, 2022

Activity Type:  Knowledge-based  

Contact Hours:  0.75 contact hours

Activity Overview

The drug formulary, or preferred drug list, is a listing of drugs covered by a payer such as health plan or pharmacy benefits manager - and is the backbone to understanding managed care pharmacy. There is extensive work done to prepare and review each medication added to the formulary. This module will detail what a formulary is and how a Pharmacy and Therapeutics Committee develops and maintains a formulary

Learning Objectives

At the completion of this activity, participants should be able to:

  • Explain what a drug formulary is and how it is developed and maintained.
  • State the composition, role, and responsibilities of a Pharmacy and Therapeutics (P&T) Committee.
  • Summarize the process that begins with the identification of a likely new drug approval and culminates in a formulary decision about the drug.
Trading Partners and Flow of Money in Managed Care Pharmacy

ACPE UAN #: 0233-0000-19-005-H04-P

Release Date:  February 1, 2019

Expiration Date:  February 1, 2022

Activity Type:  Knowledge-based  

Contact Hours:  0.75 contact hours

Activity Overview

The health care of the United States is both unique and complex. It has both state and federal oversight, and many stakeholders that must work together to ensure the systems work to get medications to patients. This module also explains the “flow of money” between these stakeholders and how specific fees are calculated.

Learning Objectives

At the completion of this activity, participants should be able to:

  • Identify the various stakeholders involved with the prescription drug benefit.
  • Explain how managed care organizations determine pharmacy reimbursement for drug products and associated dispensing fees.

Understanding Pharmaceutical Manufacturer Discounts and Rebates

ACPE UAN #: 0233-0000-19-006-H04-P

Release Date:  February 1, 2019

Expiration Date:  February 1, 2022

Activity Type:  Knowledge-based  

Contact Hours:  0.75 contact hours

Activity Overview

Managed care organizations and pharmaceutical manufacturers work very closely to negotiate drug prices. There are a few different types of price concessions that can help both organizations in the long run. This module will discuss this close relationship and how it all works.

Learning Objectives

At the completion of this activity, participants should be able to:

  • Discuss the structure and impact of rebate contracts offered by pharmaceutical manufacturers.
  •  Explain how rebates and formulary decision-making can be related.

Managed Care Pharmacy Clinical and Educational Programs

ACPE UAN #: 0233-0000-19-007-H04-P

Release Date:  February 1, 2019

Expiration Date:  February 1, 2022

Activity Type:  Knowledge-based  

Contact Hours:  0.75 contact hours

Activity Overview

The overall goals of provider and member clinical and educational programs in managed care pharmacy are to maintain a high quality of care and reduce overall health care costs.This module discussesthe role and use of clinical and educational programs pharmacy for providers and patients.

Learning Objectives

At the completion of this activity, participants should be able to:

  • Name types of pharmacy clinical and education programs that may contribute to ensuring optimal medication use by managed care plan members.
  • Analyze the factors contributing to medication adherence challenges.

Medication Therapy Management

ACPE UAN #: 0233-0000-19-008-H04-P

Release Date:  February 1, 2019

Expiration Date:  February 1, 2022

Activity Type:  Knowledge-based  

Contact Hours:  0.50 contact hours

Activity Overview

This module covers the background and goals of medication therapy management (MTM). It reviews the definition of MTM, processes and models, eligibility criteria, and other key elements of MTM.

Learning Objectives

At the completion of this activity, participants should be able to:

  • Define medication therapy management (MTM) and its key components. 
  • Discuss the benefits of MTM for patients, health systems, and payers.Summarize the impact of government and healthcare quality improvement mandates on the demand for pharmacist-conducted MTM. 
  • Describe patient eligibility for MTM services under Medicare Part D, and the types of patients most likely to benefit from non-Medicare MTM services.

Introduction to Specialty Pharmacy

ACPE UAN #:  0233-0000-19-009-H04-P

Release Date:  February 1, 2019

Expiration Date:  February 1, 2022

Activity Type:  Knowledge-based  

Contact Hours:  0.75 contact hours

Activity Overview

What is the role and impact of specialty pharmacy on managed care pharmacy? This module looks at specialty medications and what makes them “special.” Additionally, learners will review how specialty drugs are managed in order to improve outcomes and quality, and decrease costs.

Learning Objectives

At the completion of this activity, participants should be able to:

  • Describe how specialty pharmacies differ from traditional retail pharmacies
  • Discuss approaches health plans and pharmacy benefit management companies are taking to manage specialty drugs.

Medicare and Managed Care Pharmacy

ACPE UAN #: 0233-0000-19-010-H04-P

Release Date:  February 1, 2019 Expiration Date:  February 1, 2022

Activity Type:  Knowledge-based  

Contact Hours:  0.75 contact hours

Activity Overview

Medicare has greatly evolved since its early conception and has many moving parts. This module will provide an overview of how Medicare has advanced through the decades, while also providing a breakdown of its various components. Participants will gain a better understanding of the differences between Medicare Plans and discover the legal requirements behind Medicare benefits.  

Learning Objectives

At the completion of this activity, participants should be able to:

  • Explain what is covered by each of the four major components of Medicare (Part A, Part B, Part C, and Part D).
  • Discuss the requirements and structure of the standard Medicare Part D drug benefit.

Medicaid and Managed Care Pharmacy

ACPE UAN #: 0233-0000-19-011-H04-P

Release Date:  February 1, 2019

Expiration Date:  February 1, 2022

Activity Type:  Knowledge-based  

Contact Hours:  0.75 contact hours

Activity Overview

During this module, participants will become familiar with Medicaid, how it is administered and funded, listing of the services covered by Medicaid, dual eligibility, and the complexities and challenges associated with this line of business. 

Learning Objectives

At the completion of this activity, participants should be able to:

  • Explain how Medicaid is administered and funded. 
  • Summarize approaches to Medicaid pharmacy benefit management. 
  • Discuss how Medicaid differs from other lines of business.

The ABC's and Stars of Quality Measures

ACPE UAN #: 0233-0000-19-012-H04-P

Release Date:  February 1, 2019

Expiration Date:  February 1, 2022

Activity Type:  Knowledge-based  

Contact Hours:  0.75 contact hours

Activity Overview

This module describes the role of quality measures in managed care pharmacy. Learners will review the various accrediting bodies, purpose of quality measures, and types of measures. The module will further explore quality measures in the context of Medicare Stars Rating and the Quality Reporting System used in the Exchanges. 

Learning Objectives

At the completion of this activity, participants should be able to:

  • Explain how a health plan would become accredited by a national accreditation organization, such as NCQA or URAC.
  • List examples of the Healthcare Effectiveness Data and Information Set or HEDIS measures that are relevant to managed care pharmacy and describe how they are used.
  • Describe the Medicare star ratings program as well as list examples of Medicare start ratings measures that are relevant to managed care pharmacy.
  • Describe how the QRS program measures the quality of Health Insurance Marketplace Exchange programs

Faculty Relevant Financial Relationships Disclosure: 

AMCP asks everyone who is in a position to control the content of a continuing pharmacy education activity to disclose all relevant financial relationships with commercial interests. 

  • Douglas S. Bourgoyne is the Principal at Coorperative Benefits Group, LLC. He was previously employed by Magellan Rx Management. He has also consulted for Spark health and Xcenda.
  • Mary Jo Carden reports having no conflict of interest in the past 12 months.
  • Tracy McDowd is employed by OptumRx. 
    • Robert Navarro reports having no conflict of interest in the past 12 months.
    • Cindy J. Pigg is employed by Cardinal Health.
    • Debbie Stern is employed by eviCore healthcare. 
    • The following AMCP Staff report having not conflict of in the past 12 months: Brittany Vogel, Christine Cooper, Julia Veeder, Maria Miranda, Michelle Perkins, Puneet Singh, Ruby Singh.

    Method and CE Requirements:   

    Pharmacists can claim continuing pharmacy education (CPE) credit for each module separately. Learning activities are available for a specific time after the activity has been accessed or opened. Be sure to know the close date of your activities. Each activity shows a "Close Date" in the far right side next to the activity title listed in the "My Learning Activities" tab. All activities must be completed before the close date or they will expire and you will not be able to claim CPE credit.  CPE credit will be processed through the AMCP Learn portal and reported directly to CPE Monitor.  Please allow 72 hours for processing and posting in your NABP CPE Monitor account.

    Pharmacists interested in obtaining CPE credit must:

    • Successfully view the 12 recorded videos. 
    • Complete a Post-Test which requires a passing score of 70% or higher for each module.  You will be allowed three attempts to pass the post-test.
    • Complete a specific evaluation for each accredited module.

    To print your certificate of completion: 

    • After you complete the Module 12 Post-Test a   button will appear on the bottom left-hand corner. Click and print your certificate of completion.

    Please note: Certificates of Completion are only for showing completion of the online program and do not reflect any earned credits or hours.

    Accreditation Statement

    ACPE Logo

    The Academy of Managed Care Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. 

    As an accredited provider, AMCP strictly adheres to the ACPE Standards for Commercial Support and other relevant guidelines and standards to ensure the independence of continuing pharmacy education (CPE) activities. It is AMCP’s intent that all CPE activities be independent, objective, balanced, evidence-based and free of any commercial bias. 

    Copyright

    Permission has been obtained to use copyrighted materials for the Fundamentals of Managed Care Pharmacy Certificate Program 2nd Edition. Sources for all images are provided in citations.

    System Technical and Internet Requirements

    System Requirements Courses and learning activities are delivered via your Web browser and Acrobat PDF. For all activities, you should have a basic comfort level using a computer and navigating websites.  View the minimum technical and system requirements for continuing education online activities. For assistance please Contact US.

    Credit Information

    Activity Number Credit Amount Accreditation Period
    ACPE UAN #0233-0000-19-001-H04-P 0.75 Contact Hours February 01, 2019 - February 01, 2022
    ACPE UAN #0233-0000-19-002-H04-P 0.75 Contact Hours February 01, 2019 - February 01, 2022
    ACPE UAN #0233-0000-19-003-H04-P 0.75 Contact Hours February 01, 2019 - February 01, 2022
    ACPE UAN #0233-0000-19-004-H04-P 0.75 Contact Hours February 01, 2019 - February 01, 2022
    ACPE UAN #0233-0000-19-005-H04-P 0.75 Contact Hours February 01, 2019 - February 01, 2022
    ACPE UAN #0233-0000-19-006-H04-P 0.75 Contact Hours February 01, 2019 - February 01, 2022
    ACPE UAN #0233-0000-19-007-H04-P 0.75 Contact Hours February 01, 2019 - February 01, 2022
    ACPE UAN #0233-0000-19-008-H04-P 0.5 Contact Hours February 01, 2019 - February 01, 2022
    ACPE UAN #0233-0000-19-009-H04-P 0.75 Contact Hours February 01, 2019 - February 01, 2022
    ACPE UAN #0233-0000-19-010-H04-P 0.75 Contact Hours February 01, 2019 - February 01, 2022
    ACPE UAN #0233-0000-19-011-H04-P 0.75 Contact Hours February 01, 2019 - February 01, 2022
    ACPE UAN #0233-0000-19-012-H04-P 0.75 Contact Hours February 01, 2019 - February 01, 2022