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

Evolution and Principles of Managed Care

_{^{ACPEUAN #: 0233-0000-22-085-H04-P}}

_{^{Release Date:  February 1, 2022}}

_{^{Expiration Date:  December 31, 2023}}

_{^{Activity Type:  Knowledge-based}}  

_{^{Contact Hours:  0.75 contact hours}}

Activity Overview

^{Understanding the evolution of managed care pharmacy is important 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 #: 0233-0000-22-086-H04-P}}

^{_{Release Date:  February 1, 2022}}

^{_{Expiration Date:  December 31, 2023}}

^{_{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 #: 0233-0000-22-087-H04-P}}

_{^{Release Date:  February 1, 2022}}

_{^{Expiration Date:  December 31, 2023}}

_{^{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 #: 0233-0000-22-088-H04-P}}

_{^{Release Date:  February 1, 2022}}

_{^{Expiration Date:  December 31, 2023}}

_{^{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 #: 0233-0000-22-089-H04-P}}

^{_{Release Date:  February 1, 2022}}

^{_{Expiration Date:  December 31, 2023}}

^{_{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  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 #: 0233-0000-22-090-H04-P}}

_{^{Release Date:  February 1, 2022}}

_{^{Expiration Date:  December 31, 2023}}

_{^{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 #: 0233-0000-22-091-H04-P}}

^{_{Release Date:  February 1, 2022}}

^{_{Expiration Date:  December 31, 2023}}

^{_{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 discusses the 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 #: 0233-0000-22-092-H04-P}}

_{^{Release Date:  February 1, 2022}}

_{^{Expiration Date:  December 31, 2023}}

_{^{Activity Type:  Knowledge-based}}  

_{^{Contact Hours:  0.5 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 #:  0233-0000-22-093-H04-P}}

_{^{Release Date:  February 1, 2022}}

_{^{Expiration Date:  December 31, 2023}}

_{^{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 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 #: 0233-0000-22-094-H04-P}}

_{^{Release Date:  February 1, 2022}}

_{^{Expiration Date:  December 31, 2023}}

_{^{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 #: 0233-0000-22-095-H04-P}}

^{_{Release Date:  February 1, 2022}}

^{_{Expiration Date:  December 31, 2023}}

^{_{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, a 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 #: 0233-0000-22-096-H04-P}}

^{_{Release Date:  February 1, 2022}}

^{_{Expiration Date:  December 31, 2023}}

^{_{Activity Type:  Knowledge-based}}  

^{_{Contact Hours:  0.75 contact hours}}

Activity Overview

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}