Pharmacy in Managed Care

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What does the PBM do in terms of pharmacy reimbursement?

Set pharmacy reimbursement rates in individual contracts. (correct)

Control which drugs eligible members can select.

Audit pharmacies to prevent fraud.

Communicate day supply limitations to pharmacies.

How does the PBM use cost sharing and other tools to control drug selection?

By auditing pharmacies for fraud.

By recommending cost-effective benefit programs. (correct)

By checking pharmacy records for duplicate bills.

By setting day supply limitations.

What is the main purpose of a PBM auditing pharmacies?

To offer cost-effective benefit programs.

To prevent fraud. (correct)

To communicate formulary to pharmacies.

To set day supply limitations.

How does the PBM determine the cost of the drug dispensed?

Based on the volume discount received by pharmacies. Signup and view all the answers

What is one aspect of pharmacy reimbursement mentioned in the text?

Determining cost of drug dispensed. Signup and view all the answers

How do individual pharmacies potentially get a larger discount on drug products?

By buying larger volumes of drugs from wholesalers. Signup and view all the answers

What is the total reimbursement for 30 tablets of Drug X, given that the AWP for 100 tablets is $650 and the pharmacy purchases it for $533 per 100 tablets?

$145.50 Signup and view all the answers

What is the earned discount (AWP differential) for 100 tablets of Drug X?

$121.50 Signup and view all the answers

If a pharmacy can buy Drug X for $533 per 100 tablets, what is the dispensing fee for each tablet if the terms of reimbursement are AWP - 15% + $2.25?

$5.75 Signup and view all the answers

What would be the total reimbursement for 50 tablets of Drug X if the dispensing fee per tablet is $5.75?

$235.50 Signup and view all the answers

If a pharmacy can buy Drug X for $533 per 100 tablets and the AWP for 100 tablets is $650, what percentage discount does the pharmacy get?

17% Signup and view all the answers

What is the purpose of formularies in the context of PBM contracts?

To reduce ingredient costs Signup and view all the answers

What does a negative formulary list in a PBM contract indicate?

List of drugs NOT covered Signup and view all the answers

What is the primary benefit of generic substitution according to the text?

Lowering costs Signup and view all the answers

Why do PBMs negotiate drug manufacturer rebates for preferred status on formularies?

To lower costs for the sponsor Signup and view all the answers

What is a 'therapeutic switch' as mentioned in the text?

A switch from a costly drug to a cheaper alternative Signup and view all the answers

Why is therapeutic interchange sometimes difficult in community practice according to the text?

Time constraints, physician reluctance, and legal issues Signup and view all the answers

Why might maintaining participation in unprofitable 3rd party plans sometimes lead to more profit dollars at the end of the year?

Because they help to offset the pharmacy's fixed costs. Signup and view all the answers

Why might patients prefer personalized service in community pharmacies over mail-order services?

Community pharmacies offer personalized service. Signup and view all the answers

What impact can providing good service to patients have on their likelihood to use mail order pharmacies?

It slightly decreases the likelihood of patients using mail order pharmacies. Signup and view all the answers

What is a common trend regarding PBMs' reimbursement terms in recent years?

Decreasing AWP discounts and lower dispensing fees. Signup and view all the answers

What incentive do PBMs offer pharmacies to accept lower reimbursement rates and dispensing fees?

Greater business volume due to more favorable terms. Signup and view all the answers

How often do PBMs typically pay pharmacies based on the text?

Every 10 days Signup and view all the answers

What is the main difference between retrospective DUR and prospective DUR?

Retrospective DUR looks at drug patterns after the fact, while prospective DUR occurs at the time of dispensing to survey for potential problems. Signup and view all the answers

How have pharmacists adapted to survive PBM cost cutting?

By decreasing drug inventories, knowing when to reject unreasonable PBM terms, and providing clinical services. Signup and view all the answers

What steps are mentioned towards payment for advanced patient care services?

Identifying key persons in reimbursement decisions and demonstrating patient needs. Signup and view all the answers