1
Q
MCO Strategies to manage Drug Costs
A
- PCT Committee
- Drug Formulary
- Special Controls for High-cost Drugs
- Pharmaceutical Care Interventions: DUR, Disease management programs, academic detailing
2
Q
Formulary
A
- Definition: List of preferred medications developed by an issuing organization that is regularly updated
- Evaluation criteria include clinical efficacy, safety, and cost
- One of the primary reasons to develop was inventory control
- P&T Committee: advisory group that determines which drugs are included on formulary
3
Q
Open Formulary
A
- Covers broad array of drugs
- Offers more choice, but at greater cost to member/patient
4
Q
Closed Formulary
A
- Covering a more limited number of drugs
- Non formulary drugs are not covered or only covered via medical exception
5
Q
Formulary Consideration
A
- Entity establishing formulary: hospital, insurance, medical group/clinic
- Line of business/patient population needing service: commercial, Medicaid, Marketplace
- Patient population
- Pharmacy law: Federal and state, ACA mandates
6
Q
P&T Members
A
-Physicians: usually chairperson
-Pharmacists: usually secretary
-Nurses
-Administrators
-Quality Assurance Coordinators
Other: person within or outside organization who contribute specialized or unique knowledge, skills, or judgement
7
Q
P&T Formulary Responsibilities
A
- Objectively appraise, evaluate, and select drugs for the formulary
- Meet frequently enough to review and update the formulary
- Develop protocols and procedures for the use and access to non-formulary agents
8
Q
AMCP Format
A
- Provides framework to advise manufacturers regarding important health care decision maker evidence needs to evaluate new techs for formulary and coverage consideration
- Emphasize that clinical safety and efficacy should be evaluated first
- Cost effectiveness should be considered SECOND
9
Q
Pharmacy Benefit Design
A
- MCO or PBM provide pharmacy benefits that are specified and defined in a state regulated contract
- Balances patient outcomes, costs, quality, risk management and provision of services that beneficiaries expect
- Establishes coverage parameters and sets liability limits
10
Q
Tiered Drug Formulary Structure
A
- Encourages use of least expensive drug
- Most plans include tier 4/5 for specialty biologic medications: usually injectables
- Also other methods to limit use to non-covered medications like PA, step-therapy, and quantity limits
11
Q
Cost-Sharing
A
- Co-pays
- Cost-sharing (% of total)
- Cost-sharing for specialty meds can be quite high
12
Q
Typical Tiered Formulary
A
- Tier 1: Generics
- Tier 2: Brand, preferred
- Tier 3: Brand, non-preferred
- Tier 4: Preferred specialty
- Tier 5: Non-preferred specialty
13
Q
PA
A
- Patients must meet certain criteria to be prescribed a particular drug
- Can also be used when a drug is only covered for specific medical conditions
- Prescriber must provide health care plan with necessary information
14
Q
Step Therapy
A
- Type of PA
- Patient must try a particular, less expensive drug on formulary before being stepped up to more expensive drug
- Exceptions must be requested by the prescriber
15
Q
Quantity Limits
A
- For safety/costs, plan may limit amount of drugs
- Limit to 30 day supplies or total amount of drug per year
- Prescribers may request an exception
16
Q
Medicaid Formulary
A
- Must include at least one drug in every category/class or the number of drugs covered in each category/class as the base benchmark plan (whichever is greater)
- No tiers
- No cost-sharing
- Likely include PA, ST, and QL
- Open formulary for all psychotropic drugs and medications (not including ADHD or minor tranquilizers)
17
Q
Medicare Part D Formulary
A
Must include 2 drugs in each therapeutic class/category
- Likely to include PA, ST, generic drug requirements, preferred brand drugs
- Must include drugs in Antidepressant, antipsychotic, anticonvulsant, immunosuppressant, antineoplastic, and HIV/AIDS categories
18
Q
Formulary Immediate Changes
A
- Removal due to FDA Safety determination
- Remove brand name and replace with newly available generic
- Other changes: must provide 30 day notice to CMS, or at refill request provide a 30 day supply of removed drug with written notice of change
836
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Decks in class (15)
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