Maaged Care Pharmacy Best practices that offer quality care ad cost-effective coverage to patiets, payers, employers, ad govermet Pharmacists are Medicatio Experts Electroic Prior Authorizatio (epa) Step Therapy Medicatio Therapy Maagemet Mail Service Pharmacy
Quality assurace programs to ehace patiet safety ad service Medicatio maagemet programs that improve patiet health Welcome to the world of Maaged Care Pharmacy Maaged Care Pharmacists Desig ad Implemet: Fraud, waste ad abuse programs to decrease misuse of medicatios ad drug diversio Drug beefit programs to esure broad patiet access to eeded medicatios I the health isurace purchasig marketplace, the payers (commercial market ad govermet) usually have three major cocers: 1. Providig employees with a meaigful beefit package 2. Moderatig the amout of employee out-of-pocket costs 3. Moderatig the cost impact o the employer s bottom lie Whe the payer shops for a beefit package that meets its criteria, it seeks a health pla to provide costeffective health beefits. Maaged care pharmacy has developed a variety of maaged care pharmacy strategies utilized by commercial health plas ad govermet maaged programs like Medicaid that are used to moderate costs while providig a safe, cliically effective ad valuable prescriptio drug beefit. The payer selects those strategies that best fit their employee eeds ad busiess operatios. AMCP 1
Pharmacists are highly traied medicatio experts! Formulary Developmet by Pharmacy & Therapeutics (P&T) Committees Drug Utilizatio Review (DUR) Pharmacists ofte ear a bachelor s degree, ad complete four years of graduate coursework resultig i a Doctor of Pharmacy degree (PharmD), with the greatest cocetratio i pharmaceutical educatio compared to doctors ad all other health care professioals. I additio, may pharmacists seek further traiig ad specializatio through residecies ad fellowships. Pharmacists are life-log learers who pursue cotiuig educatio to maitai their licese ad stay curret o chages i pharmaceutical sciece, health policy, ad research. Maaged Care Pharmacists are resposible for the developmet ad use of a broad ad diversified rage of cliical ad quality-orieted drug maagemet services. Maaged Care Pharmacists are also ivolved i maagemet of populatio health ad provide patiet-cetered care as a itegral ad valuable member of the health care team. Maaged Care Pharmacists fill may roles: Esurig patiet safety Coduct Drug Utilizatio Review (DUR) Serve o Pharmacy ad Therapeutics (P&T) Committees Desig Medicatio Therapy Maagemet (MTM) programs Develop Quality Assurace Programs Create programs to detect fraud, waste ad abuse of medicatios Drug beefit desig Help cliets evaluate ad improve their pharmacy beefit 2 Academy of Maaged Care Pharmacy
PHARMACISTS ARE HIGHLY TRAINED MEDICATION EXPERTS: Formulary Developmet by Pharmacy & Therapeutics (P&T) Committees P&T Committees cotiually develop, maage, ad update formularies as ew medicatios become available. These committees are made up of physicias, pharmacists, ad urses. P&T COMMITTEES P&T Committees iclude health care professioals who keep formularies updated regularly. FORMULARY A formulary, also kow as a preferred medicatio list, is a cotiually updated list of medicatios ad related products. THERAPEUTIC CLASS Therapeutic classificatio systems group medicatios with similar uses or actios ito a tier. P&T Committees review... Medicatio formularies to promote safety, effectiveess, ad affordability Therapeutic classes to update ad implemet best practices Peer-reviewed literature ad cliical trials Health care professioals icludig prescribers ad pharmacists collaborate to icrease access to safe, cost-effective ad evidece based medicatio therapy. Pharmaceutical iovatio ow focuses primarily o high-cost specialty ad biologics, makig formulary developmet more importat tha ever. Formulary systems use P&T Committees to evaluate cliical ad medical literature whe selectig the preferred medicatios for differet diseases ad coditios that best serve a pla s patiet populatio. Drug Tiers The P&T Committees assig medicatios ito a Drug Tier by utilizig cliical ad cost iformatio. Medicatios are assiged to tiers based o medicatio usage, cost, ad, most importatly, effectiveess. Tier 1 drugs are the most accessible to patiets i terms of usage ad lower out of pocket costs. The higher tiers will have differet copay resposibilities due to the higher cost of the medicatios. Some states have eacted laws that require a drug to be o a certai tier. The cost of the drug is determied by the maufacturer ad the distributor, ot the health pla, payor, PBM, or the employer. TIER 1 TIER 2 TIER 3 TIER 4 Specialty No-Preferred Preferred Geerics Newest, greatest potetial for risk, least amout of evidece, most expesive Example illustratio. Tier structure differs by health pla. Most plas have betwee 1 4 tiers. Least potetial for risk, sigificat evidece, least expesive AMCP 3
PHARMACISTS ARE HIGHLY TRAINED MEDICATION EXPERTS: Drug Utilizatio Review (DUR) A comprehesive, iteral review of a patiet s prescriptio ad medical iformatio at regular stages of treatmet i order to esure patiet safety ad evaluate cost-savig opportuities. Prospective DUR Medical ad medicatio therapy iformatio is evaluated prior to dispesig a patiet s ew medicatio for: Drug-drug ad drug-disease iteractios Dosig appropriateess Medicatio allergies Medicatio directios Cocurret DUR The patiet s therapy is evaluated durig the treatmet process for: Over or uderutilizatio of medicatio Excessive or isufficiet dosig Drug-drug iteractios Retrospective DUR Previously admiistered medicatios are evaluated to reveal treds i prescribig, admiisterig, ad dispesig of medicatios, icludig: Reviewig patiet charts or electroic medical records Idetifyig patters to prevet iappropriate use of medicatios Developig stadard guidelies to achieve target outcomes at a populatio level 4 Academy of Maaged Care Pharmacy
PHARMACISTS ARE HIGHLY TRAINED MEDICATION EXPERTS: Drug Utilizatio Review (DUR) cot d This asthma is really slowig me dow. This prescriptio is t helpig much. Example Sceario: Tim s asthma is ot well cotrolled, ad he uses his ihaler multiple times a day. Tim s therapy should most likely be icreased to prevet further medical complicatios. Pharmacist Iteractio: A pharmacist coducted a cocurret DUR at the health pla ad oticed that Tim was oly prescribed a as-eeded ihaler. With the pharmacist s recommedatio to the prescriber, derived from evidece-based guidelies, Tim was prescribed a maiteace asthma medicatio. Beefit: Although aother medicatio was added, the patiet ad the health pla have a overall cost savigs. The added prescriptio vastly decreases Tim s likelihood of a costly emergecy room visit for a severe asthma attack ad ehaces Tim s quality of life. AMCP 5
Electroic Prior Authorizatio (epa) A process desiged to esure that the medicatios patiets receive are safe, effective ad provide the greatest value. epa is a automated process which provides real-time resposes. PRIOR AUTHORIZATION Prior Authorizatio is the process of obtaiig permissio from a health isurace compay before a certai medicatio is approved. Maaged Care Pharmacists take care to esure that medicatio is used appropriately i their patiet populatio. Prior Authorizatios (PAs) require approval of certai medicatios to esure appropriateess based o cliical evidece. This additioal step guaratees that the prescriptio is medically ecessary whe a cliically effective, less expesive optio is available. The PA will be approved by the health pla if the patiet s coditio meets the ecessary requiremets. The NCPDP SCRIPT stadard-based epa reduces health care costs, improves patiet ad prescriber experiece ad provides real-time resposes. Step Therapy The use of a prove, cliically effective prescriptio prior to tryig a riskier or more costly optio. The majority of prescriptios are ot subject to step therapy programs. Maaged Care Pharmacists determie if a medicatio is preferred based o effectiveess, safety, ad cost. Step Therapy requires the use of a preferred medicatio prior to begiig aother medicatio for the same coditio or i the same therapeutic class. This may require use of a medicatio differet from what was origially prescribed. After talkig to the prescriber, the patiet always has the optio to pay for the origial medicatio prescribed without usig the prescriptio beefit. Also the prescriber ca provide additioal iformatio about the patiet s medical history which may result i the origial prescriptio beig approved. STEP THERAPY Step Therapy ecourages the use of cliically prove ad cost effective medicatios prior to usig ewer medicatios that ofte have a shorter history of cliical effectiveess ad a higher cost. 6 Academy of Maaged Care Pharmacy
Step Therapy cot d Is there a cliically effective more affordable medicatio tha the oe that my doctor prescribed? Example Sceario: Midy has a prescriptio for a medicatio that is ew o the market. The pharmacist explais that her isurace requires her to try a differet medicatio first because it is as effective ad will cost her less. Pharmacist Iteractio: The prescriber ad pharmacist discuss the patiet s optios. The pharmacist iforms the prescriber that if Midy decides to take the preferred medicatio ad experieces side effects or if the medicatio is ieffective for her, the isurace may cover the origially prescribed medicatio after the prescriber provides additioal iformatio to the isurace compay cocerig the patiet s medical history. Beefit: The health pla s preferred medicatio worked as iteded for Midy. The medicatio achieved a idetical medical outcome for less tha half the cost of the origially prescribed medicatio. AMCP 7
Medicatio Therapy Maagemet (MTM) Services that idetify ad address medicatio-related problems ad medicatio mismaagemet, ad help the patiet uderstad proper medicatio usage. Certai patiets erolled i Medicare Part D ad employer-sposored beefit plas receive this service. MTM beefits patiets who... Use several medicatios for multiple health coditios Take medicatios that require careful moitorig Chage from oe health care settig to aother, such as from the hospital to the home or from the home to a log-term care facility Receive medicatios from multiple pharmacies Go over ALL my medicatios ad labs to make my treatmet better?... YES, P LEASE!!! Example Sceario: George has multiple medical coditios ad wats to take his health care seriously. He remembers the pharmacist tellig him that he may beefit from his pla s MTM cosult program, so he calls ad sets up a appoitmet. Pharmacist Iteractio: The pharmacist was stued by the fidigs. George has t bee takig his diabetes medicatio for three moths. George assumed he did t eed it because the physicia did t give him a prescriptio refill at his last visit. The cosult idetified gaps i care, the pharmacist cosulted with the physicia, ad George bega takig his medicatios agai. Beefit: Because George cotiued his medicatio, the pharmacist potetially preveted George from visitig the emergecy departmet or beig hospitalized ad may have saved his life. MTM also resulted i cost savigs for George ad George s employer ad health pla, which did ot have to subsidize costly medical itervetios. More importatly, it resulted i George havig a positive health outcome. 8 Academy of Maaged Care Pharmacy
Mail Service Pharmacy The optio of receivig maiteace medicatios ad medical supplies through the mail. Chroic coditios ofte require log-term use of medicatios. Mail service pharmacies help esure patiets receive medicatios i a timely maer, which prevets gaps betwee prescriptio refills. MAIL SERVICE PHARMACY Mail Service Pharmacies offer the coveiece of home delivery for maitaiig prescriptio drug therapy at a lower cost. The ability of mail service pharmacies to purchase high volumes of medicatio may also offer a reduced drug price ad lower co-pay to the patiet. However, a patiet usually retais the ability to travel to a local pharmacy ad have a differet copay for the maiteace drugs. My medicatios will come right to my door ad cost less? Example Sceario: Peter will likely be takig his ew medicatios log term. He has trouble fidig time to get to the pharmacy due to his job schedule ad ofte picks up his prescriptios late. At the pharmacy, the pharmacist explais to Peter that his isurace offers mail order. Result: Peter ow receives his medicatio automatically every three moths ad o loger misses doses. Peter still uses his commuity pharmacy for other prescriptios ad retail eeds. Beefit: Usig a mail service pharmacy, he ow saves moey o each co-pay ad does ot eed to remember to make trips to the pharmacy. Most importatly, Peter is healthier ad at a lower risk of complicatios.
INFORMATION. WHEN YOU NEED IT. To access AMCP s website ad lear more about who AMCP is ad what we do, visit www.amcp.org. amcp.org/li @amcporg Facebook.com/AMCPFa 675 N Washigto Street Suite 220 Alexadria, VA 22314 Tel 703/684-2600 www.amcp.org MAR 2017 / 1000