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.
Release Date: July 25, 2016
Expiration Date: July 25, 2019
Activity Fee: AMCP Student Member: $199 Non-Member: $249
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.
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.
- Outline the evolution of managed care in the United States.
- 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.
- Discuss common strategies used to manage the cost of medications and demand for medications in a pharmacy benefit.
- Recognize how various drug cost and utilization management strategies can be combined to design a customized pharmacy benefit.
- List the steps involved in adjudicating a traditional managed prescription drug claim.
- Explain how the adjudication of a managed prescription drug claim differs with electronic prescribing.
- State the composition, role, and responsibilities of a Pharmacy and Therapeutics (P&T) Committee.
- Summarize the process that begins with the identification of a likely new drug approval and culminates in a formulary decision about the drug.
- Explain how managed care organizations determine pharmacy reimbursement for drug products and associated dispensing fees.
- Discuss the structure and impact of rebate contracts offered by pharmaceutical manufacturers.
- Describe the components of medication therapy management services.
- Name other types of pharmacy clinical programs that may contribute to ensuring optimal medication use by managed care plan members.
- Recognize characteristics that define a specialty medication.
- Explain why specialty medications pose special challenges for health plans and pharmacy benefit management companies.
- Describe how specialty pharmacies differ from traditional retail pharmacies.
- Discuss approaches health plans and pharmacy benefit management companies are taking to control specialty medication costs.
- Outline major components and requirements of the Affordable Care Act.
- Explain what the Health Insurance Marketplace is and how it works for individuals and small businesses.
- Discuss the different types of plans available through the Health Insurance Marketplace.
- Report experience to date with implementation of the Affordable Care Act.
- Explain what is covered by each of the four major components of Medicare (Part A, Part B, Part C, and Part D).
- Summarize differences between original Medicare and Medicare Advantage plans.
- Summarize differences between Medicare prescription drug plans (PDPs) and Medicare Advantage prescription drug (MA-PD) plans.
- Discuss the requirements and structure of the standard Medicare Part D drug benefit.
- Describe the changes to Medicare imposed by the Affordable Care Act (ACA).
- Explain how Medicaid is administered and funded.
- List mandatory and optional services covered by Medicaid.
- Summarize current approaches to Medicaid pharmacy benefit design.
- Discuss how prescribing drug coverage is handled for “dual eligible” beneficiaries.
- Describe changes to Medicaid imposed by the Affordable Care Act (ACA).
- Explain how a health plan would become accredited by the National Committee for Quality Assurance (NCQA) or URAC.
- List examples of Healthcare Effectiveness Data and Information Set (HEDIS) measures that are relevant to managed care pharmacy and describe how they are used.
- Discuss the role of the Pharmacy Quality Alliance (PQA) in developing performance measures related to medication use.
- 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
To earn a certificate of completion partifipants must:
- Successfully view the 11 pre-recorded presentations (approximately 9 hours total viewing).
- 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.
To print your certificate of completion:
- After you complete the Module 11 Post-Test a button will appear on the bottom left hand conner. Click and print your certificate of completion.
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 web sites. View the minimum technical and system requirements for continuing education online learning activities. Contact US.
Permission has been obtained to use copyrighted materials for the Fundamentals of Managed Care Pharmacy Certificate Program. Sources for all images are provided in citations.