29 Questions
What does the PBM do in terms of pharmacy reimbursement?
Set pharmacy reimbursement rates in individual contracts.
How does the PBM use cost sharing and other tools to control drug selection?
By recommending cost-effective benefit programs.
What is the main purpose of a PBM auditing pharmacies?
To prevent fraud.
How does the PBM determine the cost of the drug dispensed?
Based on the volume discount received by pharmacies.
What is one aspect of pharmacy reimbursement mentioned in the text?
Determining cost of drug dispensed.
How do individual pharmacies potentially get a larger discount on drug products?
By buying larger volumes of drugs from wholesalers.
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
What is the earned discount (AWP differential) for 100 tablets of Drug X?
$121.50
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
What would be the total reimbursement for 50 tablets of Drug X if the dispensing fee per tablet is $5.75?
$235.50
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%
What is the purpose of formularies in the context of PBM contracts?
To reduce ingredient costs
What does a negative formulary list in a PBM contract indicate?
List of drugs NOT covered
What is the primary benefit of generic substitution according to the text?
Lowering costs
Why do PBMs negotiate drug manufacturer rebates for preferred status on formularies?
To lower costs for the sponsor
What is a 'therapeutic switch' as mentioned in the text?
A switch from a costly drug to a cheaper alternative
Why is therapeutic interchange sometimes difficult in community practice according to the text?
Time constraints, physician reluctance, and legal issues
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.
Why might patients prefer personalized service in community pharmacies over mail-order services?
Community pharmacies offer personalized service.
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.
What is a common trend regarding PBMs' reimbursement terms in recent years?
Decreasing AWP discounts and lower dispensing fees.
What incentive do PBMs offer pharmacies to accept lower reimbursement rates and dispensing fees?
Greater business volume due to more favorable terms.
How often do PBMs typically pay pharmacies based on the text?
Every 10 days
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.
How have pharmacists adapted to survive PBM cost cutting?
By decreasing drug inventories, knowing when to reject unreasonable PBM terms, and providing clinical services.
What steps are mentioned towards payment for advanced patient care services?
Identifying key persons in reimbursement decisions and demonstrating patient needs.
When does Prospective DUR occur?
At the time of dispensing a drug.
What is another name for Prospective DUR?
Soft Edit
What have P&T committee members shown interest in regarding drug use?
Patterns of drug use.
Learn about the profitability of maintaining participation in unprofitable third-party plans in pharmacies. Discover how these plans can help offset fixed costs and contribute to overall profit dollars at the end of the year.
Make Your Own Quizzes and Flashcards
Convert your notes into interactive study material.
Get started for free
