definitions acronyms and math
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| PBM marketing | Who markets rebate contracting, flexibility in custom claim design, custom formularies, MTM
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| Where are health choice pharmacy benefits compared to medicaid | Health choice - Carved out run by medcoMedicaid - benefits are not carved out
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| Why was medicare part-d moved to private sector? | due to lobbying from PBM's
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| 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
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| Future pharmacy trends (3) | 1. More overall RX volume 2. Specialty pharmacy growth: injectables/biotech therapies also pharmacogenomics 3. Specialty pharmacy focused on disease
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| 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
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| Who oversees medicaid | Overseen by CMS (Center for Medicare and Medicaid Services) within HHS (health and human services department
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| What's the role of CMS in Medicaid? | Sets requirements and monitors... funding, qualifying guidelines, quality of service, and extent of covered services
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| 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
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| Who qualifies for Medicaid? | Temporary Aid to Needy families (TANF): mom's and kids. aged, blind/disable, dual eligible.
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| 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?
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| 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
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| what is MMIS? | Medicaid Management information system MMIS! Where pharmacy claims processing occurs. For OK, this is done by HP/EDS
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| 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.
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| What model is Medicaid moving towards? | Medicaid is transitioning to Medical Home Model: a single physician coordinating care. TANF is moving towards managed care.
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| 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.
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| 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
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| 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.
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| 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.
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| What is most favored nation? | BY LAW, Medicaid will get the best price given to any other buyer of medications.
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| 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%
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| timeframe of baby boomers | 2010 baby boomers reach retirement age. 2030 1 in 5 will be over age 65.
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| Components of Medicare: A and B | A - inpatient hospital services, some nursing home/hospice. B - physician visits and in-office meds
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| 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
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| What's a PDP? | prescription drug plan that stands alone. MAPD is a medicare advantage prescription drug program.
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| Is healthchoice a PDP? | yes, it's approved for tax free subsidies for their employer retiree benefit program
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| 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.
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| 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
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| 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
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| 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.
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| what's the primary goal of a formulary? | To promote safe, effective, and appropriate therapy. It is not to decrease costs.
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| 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
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| General formulary structure | Tier 1: generic meds at $10-15 copaysTier 2: Preferred brand names at $25-35/copayTier III: non-pref brands
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