Fundamentals of Managed Care Pharmacy Certificate Program - Professional Version

This video clip is an excerpt from Module 5:  Trading Partners and Flow of Money in Managed Care, featuring narration by Robert P. Navarro, PharmD.

ACPE UAN #:   0233-0000-16-038-H04-P

Release Date:  July 25, 2016

Expiration Date:  July 25, 2019

Activity Type:  Knowledge-based  

Contact Hours:  15 contact hours

Activity Fee:      AMCP Member:  $399       Non-Member: $499

Activity Overview

The Fundamentals of Managed Care Pharmacy Certificate Program provides a comprehensive introduction to basic concepts in managed care pharmacy. Previously presented live at AMCP meetings, it has been updated and repurposed as an online certificate program, with the help of key thought-leaders.   Learners will explore key aspects of managed care pharmacy, including core fundamental modules and four focused content areas: Medicare Part D, Medicaid, Affordable Care Act, and Quality Ratings.  Pharmacists can earn a maximum of 15 contact hours (1.5 CEUs) of CPE credit for the Fundamentals of Managed Care Pharmacy Certificate online program

Target Audience

This program is designed for pharmacists, managed care/managed markets team members, and other individuals who are interested in expanding their understanding of managed prescription drug benefits.

Learning Objectives:

  1. Outline the evolution of managed care in the United States.
  2. Identify and describe key managed care entities, including plan sponsors, health maintenance organizations, preferred provider organizations, point-of-service plans, high-deductible health plans, and pharmacy benefit management companies.
  3. Discuss common strategies used to manage the cost of medications and demand for medications in a pharmacy benefit.
  4. Recognize how various drug cost and utilization management strategies can be combined to design a customized pharmacy benefit.
  5. List the steps involved in adjudicating a traditional managed prescription drug claim.
  6. Explain how the adjudication of a managed prescription drug claim differs with electronic prescribing.
  7. State the composition, role, and responsibilities of a Pharmacy and Therapeutics (P&T) Committee.
  8. Summarize the process that begins with the identification of a likely new drug approval and culminates in a formulary decision about the drug.
  9. Explain how managed care organizations determine pharmacy reimbursement for drug products and associated dispensing fees.
  10. Discuss the structure and impact of rebate contracts offered by pharmaceutical manufacturers.
  11. Describe the components of medication therapy management services.
  12. Name other types of pharmacy clinical programs that may contribute to ensuring optimal medication use by managed care plan members.
  13. Recognize characteristics that define a specialty medication.
  14. Explain why specialty medications pose special challenges for health plans and pharmacy benefit management companies.
  15. Describe how specialty pharmacies differ from traditional retail pharmacies.
  16. Discuss approaches health plans and pharmacy benefit management companies are taking to control specialty medication costs.
  17. Outline major components and requirements of the Affordable Care Act.
  18. Explain what the Health Insurance Marketplace is and how it works for individuals and small businesses.
  19. Discuss the different types of plans available through the Health Insurance Marketplace.
  20. Report experience to date with implementation of the Affordable Care Act.
  21. Explain what is covered by each of the four major components of Medicare (Part A, Part B, Part C, and Part D).
  22. Summarize differences between original Medicare and Medicare Advantage plans.
  23. Summarize differences between Medicare prescription drug plans (PDPs) and Medicare Advantage prescription drug (MA-PD) plans.
  24. Discuss the requirements and structure of the standard Medicare Part D drug benefit.
  25. Describe the changes to Medicare imposed by the Affordable Care Act (ACA).
  26. Explain how Medicaid is administered and funded.
  27. List mandatory and optional services covered by Medicaid.
  28. Summarize current approaches to Medicaid pharmacy benefit design.
  29. Discuss how prescribing drug coverage is handled for “dual eligible” beneficiaries.
  30. Describe changes to Medicaid imposed by the Affordable Care Act (ACA).
  31. Explain how a health plan would become accredited by the National Committee for Quality Assurance (NCQA) or URAC.
  32. List examples of Healthcare Effectiveness Data and Information Set (HEDIS) measures that are relevant to managed care pharmacy and describe how they are used.
  33. Discuss the role of the Pharmacy Quality Alliance (PQA) in developing performance measures related to medication use.
  34. List examples of Medicare star rating measures that are relevant to managed care pharmacy and describe how they are used.

Schedule of Educational Activity

This is an online certificate of completion program consisting of 11 modules. Here is a listing of all modules:

Module 1:  Evolution and Principles of Managed Care

Module 2:  Pharmacy Benefit Management Toolkit

Module 3:  From Contract to Bottle: Getting Medications to Patients

Module 4:  Developing and Managing the Drug Formulary

Module 5: Trading Partners and Flow of Money in Managed Care Pharmacy

Module 6:  Managed Care Pharmacy Clinical and Educational Programs

Module 7:  Introduction to Specialty Pharmacy

Module 8:  Health Care Reform and Impact on Prescription Drug Programs

Module 9:  Medicare and Managed Care Pharmacy

Module 10:  Medicaid and Managed Care Pharmacy

Module 11:   The ABCs and Stars of Quality Measures

Method and CE Requirements:   

Pharmacists can claim continuing pharmacy education (CPE) credit for this certificate program once Module 11 is completed. Important: All continuing pharmacy education (CPE) credit(s) must be claimed within 60 days of enrolling in an online activity.   Learn More Learning activities are available for a specific time after the activity has been accessed or opened. Be sure to know the close date of your activities. Each activity shows a "Close Date" in the far right side next to the activity title listed in the My Learning Activities tab. All activities must be completed before the close date or they will expire and you will not be able to claim CPE credit.  CPE credit will be processed through the AMCP Learn portal and reported directly to CPE Monitor.  Please allow 72 hours for processing and posting in your NABP CPE Monitor account.

Pharmacists interested in obtaining CPE credit must:

  • Successfully view the 11 pre-recorded presentations (approximately 9 hours total viewing time).
  • Complete a Post-Test which requires a passing score of 70% or higher for each module.  You will be allowed three attempts to pass the post-test.
  • Complete a specific evaluation for the entire program.

To print your certificate of completion: 

  • After you complete the Module 11 Post-Test a  button will appear on the bottom left-hand corner. Click and print your certificate of completion.

Please note: Certificates of Completion are only for showing completion of the online program and do not reflect any earned credits or hours.

System Technical and Internet Requirements

System Requirements Courses and learning activities are delivered via your Web browser and Acrobat PDF. For all activities, you should have a basic comfort level using a computer and navigating websites.  View the minimum technical and system requirements for continuing education online learning activities. Contact US.

Faculty Relevant Financial Relationships Disclosure: 

AMCP asks everyone who is in a position to control the content of a continuing pharmacy education activity to disclose all relevant financial relationships with commercial interests. If AMCP determines that a conflict of interest exists as a result of a financial relationship you have (or that your spouse/partner has), we will need to take appropriate steps to resolve the conflict of interest.

  • Douglas S. Burgoyne, PharmD, has received honoraria for serving as a consultant to AstraZeneca, Bristol-Myers Squibb, Novo Nordisk, Purdue Pharma, and Sanofi.
  • Mary Jo Carden, RPh, JD, reports having no financial relationships with any commercial interests during the past 12 months.
  • Tracy McDowd, PharmD, reports having no financial relationships with any commercial interests during the past 12 months.
  • Robert P. Navarro, PharmD, has received honoraria for serving as a consultant to Actavis/Forest Laboratories, Biogen Idec, Genentech, InterMune, and Purdue Pharma.
  • Cynthia J. Pigg, BSMT, BSPharm, MHA, FAMCP, reports having no financial relationships with any commercial interests during the past 12 months.
  • Debbie Stern, RPh, is an employee of eviCore Healthcare.
  • The AMCP staff members involved in developing the Fundamentals of Managed Care Pharmacy Certificate Program, report having no financial relationships with any commercial interests during the past 12 months.

The Academy of Managed Care Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. 

As an accredited provider, AMCP strictly adheres to the ACPE Standards for Commercial Support and other relevant guidelines and standards to ensure the independence of continuing pharmacy education (CPE) activities.  It is AMCP’s intent that all CPE activities be independent, objective, balanced, evidence-based and free of any commercial bias. 


Permission has been obtained to use copyrighted materials for the Fundamentals of Managed Care Pharmacy Certificate Program. Sources for all images