Pharmacy in Managed Care
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Questions and Answers

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?

    <p>Based on the volume discount received by pharmacies.</p> Signup and view all the answers

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

    <p>Determining cost of drug dispensed.</p> Signup and view all the answers

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

    <p>By buying larger volumes of drugs from wholesalers.</p> 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?

    <p>$145.50</p> Signup and view all the answers

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

    <p>$121.50</p> 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?

    <p>$5.75</p> 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?

    <p>$235.50</p> 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?

    <p>17%</p> Signup and view all the answers

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

    <p>To reduce ingredient costs</p> Signup and view all the answers

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

    <p>List of drugs NOT covered</p> Signup and view all the answers

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

    <p>Lowering costs</p> Signup and view all the answers

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

    <p>To lower costs for the sponsor</p> Signup and view all the answers

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

    <p>A switch from a costly drug to a cheaper alternative</p> Signup and view all the answers

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

    <p>Time constraints, physician reluctance, and legal issues</p> 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?

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

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

    <p>Community pharmacies offer personalized service.</p> Signup and view all the answers

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

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

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

    <p>Decreasing AWP discounts and lower dispensing fees.</p> Signup and view all the answers

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

    <p>Greater business volume due to more favorable terms.</p> Signup and view all the answers

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

    <p>Every 10 days</p> Signup and view all the answers

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

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

    How have pharmacists adapted to survive PBM cost cutting?

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

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

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

    When does Prospective DUR occur?

    <p>At the time of dispensing a drug.</p> Signup and view all the answers

    What is another name for Prospective DUR?

    <p>Soft Edit</p> Signup and view all the answers

    What have P&T committee members shown interest in regarding drug use?

    <p>Patterns of drug use.</p> Signup and view all the answers

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