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Pharm Man exam 2

definitions acronyms and math

QuestionAnswer
PBM marketing Who markets rebate contracting, flexibility in custom claim design, custom formularies, MTM
Where are health choice pharmacy benefits compared to medicaid Health choice - Carved out run by medcoMedicaid - benefits are not carved out
Why was medicare part-d moved to private sector? due to lobbying from PBM's
What is health choices unique status? They're a employer PDP plan. They get 28% of money from medicare for pt meds from $250-$5000
Future pharmacy trends (3) 1. More overall RX volume 2. Specialty pharmacy growth: injectables/biotech therapies also pharmacogenomics 3. Specialty pharmacy focused on disease
When was medicaid created? title 19 of the social security act of 1965. Makes coverage available for basic health and long-term services based on need
Who oversees medicaid Overseen by CMS (Center for Medicare and Medicaid Services) within HHS (health and human services department
What's the role of CMS in Medicaid? Sets requirements and monitors... funding, qualifying guidelines, quality of service, and extent of covered services
What's the role of States in Medicaid? Establish recipient eligibility. Determine services offered above the minimum. Allow freedom of choice throughout the state. set reimbursement rates. define the org/admin str
Who qualifies for Medicaid? Temporary Aid to Needy families (TANF): mom's and kids. aged, blind/disable, dual eligible.
Eligibility requirements for Medicaid Mandated at 2 lev:state and federal. Big category is TANF. Needy is determined as % of FPL (federal poverty level) Dual eligibles transferred to Medicare?
By law, what's the minimum FPL coverage for medicaid? depending on the graph, it's between 100 and 133% of the FPL federal poverty line
what is MMIS? Medicaid Management information system MMIS! Where pharmacy claims processing occurs. For OK, this is done by HP/EDS
What was oklahoma's 2009 FMAP? The Federal Medical Assistance Program (FMAP) is 66%, so the feds give 66% of every dollar medicaid spends. Currently it's 75% for 2010.
What model is Medicaid moving towards? Medicaid is transitioning to Medical Home Model: a single physician coordinating care. TANF is moving towards managed care.
How is medicaid reimbursed in some states? They are carving out pharmacy benefit from capitation to fee for service. Copays charged to over 21y/o.
What are medicaid copays? after april 1: $2 if drug<$29.99 and $3 if it's over... before april 1 it's $1/2
What about medicaid drug rebates? if a drug has a rebate, medicaid must cover unless it's optional/excluded category. This rebate ensures medicaid gets the best price.
What's Obra 90? omnibus budget reconciliation act of 1990. ONLY outpatient drugs. MFR signs 1 contract w/CMS. states lose FFP (federal financial participation) if state pays for a drug w/no rebate.
What is most favored nation? BY LAW, Medicaid will get the best price given to any other buyer of medications.
What's a PDL? A preferred drug list is a list prescribers can write for without prior auth problems. These meds are discounted 15.1-30% of regular price because a state can get additional rebates. average = 30%
timeframe of baby boomers 2010 baby boomers reach retirement age. 2030 1 in 5 will be over age 65.
Components of Medicare: A and B A - inpatient hospital services, some nursing home/hospice. B - physician visits and in-office meds
Part C and D of medicare C-medicare advantage - allows choice of option from traditional medicare service. D-outpatient meds. people can buy supplements, vision or dental
What's a PDP? prescription drug plan that stands alone. MAPD is a medicare advantage prescription drug program.
Is healthchoice a PDP? yes, it's approved for tax free subsidies for their employer retiree benefit program
With addition of CHIP and soonercare, what's the FPL for pregnant women and children up to age 18? The cutoff with additional state funding is 185% of FPL.
What's a pt's med money responsibility in part D in 2006? first $295 deductible, then 25% w/other 75% paid by plan up to $2250 in total drug costs. At $5100 in total costs, the hole ends and the gov't pays 80%, the plan pays 15%, and the patient pays 5% of medications
Management of PDP plan? P&T committee, w/health care providers focused on geriatric care. Formulary is reviewed by CMS. Beer's criteria for med use by elderly. Comprehensive pharmacy network. MTM for individuals w/over $4000 in meds/year
Hx of Formularies in managed care: open/closed 1960's every hospital had an open formulary-covered broad array of meds. closed formulary-covering a limited number of meds.
what's the primary goal of a formulary? To promote safe, effective, and appropriate therapy. It is not to decrease costs.
Generic 1st formulary vs. generic only form.. gen 1st (step therapy) is good because it offers low cost and clinical benefit for those drugs that have no generic... gen only-not clinically safe
General formulary structure Tier 1: generic meds at $10-15 copaysTier 2: Preferred brand names at $25-35/copayTier III: non-pref brands
Created by: nickh88 on 2010-04-12



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