Fundamentals of Managed Care Pharmacy | 2nd Edition

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:

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

Activity Overview

Learning Objectives

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

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

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:

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

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:

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

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:

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

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:

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

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:

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

Learning Objectives

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

1. Define medication therapy management (MTM) and its key components. 
2. 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. 
3. Describe patient eligibility for MTM services under Medicare Part D, and the types of patients most likely to benefit from non-Medicare MTM services.

Learning Objectives

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

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

Learning Objectives

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

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

Learning Objectives

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

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

Learning Objectives

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

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