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Module 9

Section 4: Third-party cost controls

QuestionAnswer
Why do pharmacy benefit managers create lists of medications that are covered or excluded from coveragae? To control prescriptions cost
Pharmacy benefit managers control prescription costs by encouraging pharmacies to select which types of medications? Generic equivalents Therapeutic equivalents
What are the two types of formularies used by pharmacy benefit managers, and what do they indicate? Positive formulary (lists medications that are covered) Negative formulary (lists medications that are excluded from coverage)
What is a restriction often found in positive formularies? Positive formularies may only cover certain medications within a therapeutic class.
Which types of medications are included in a negative formulary? Cosmetics weight-control products Experimental medications Parenteral medications other than insulin Most compounded medications
What is a MAC provision? The maximum amount a payer will pay for certain medications (originally used by the federal government for state Medicaid reimbursements)
When is it necessary for a pharmacy technician to provide a Dispense as Written (DAW) code when submitting a claim? When a health care provider requires a brand-name medication by indicating DAW on the prescription form
Why are claims initially processed using the quantity and day supply written by the prescriber even if the pharmacy technician knows it will be rejected? To provide documentation of due diligence if the quantity is changed or the prior authorization process is initiated.
Which types of medications may not be subject to 30-day supply limits imposed by pharmacy benefit managers? Specific maintenance medications taken for chronic conditions, such as blood pressure medications.
What is used to monitor patterns of prescribing, dispensing, and dosing of prescription medications? Drug utilization review (DUR)
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