Table of Contents
Acknowledgments
About the Author
Chapter 1 Prescription Benefits Today-An Overview
Prescription Drug Stakeholders
Factors Influencing Prescription Spending
Research and Development (R&D)
Marketing and Sales
Market Competition
Demographic Changes
Generic Drugs: One Solution to Higher Drug Spending
Why Generics Cost Less
Public Acceptance of Generics
Generic Substitution
The Future of Generics
Chapter 2 Pharmacy Benefit Management
The Evolution of Prescription Drug Benefit Management
Challenges Facing Disease State Management
Cost Containment Versus Cost-Effectiveness
Communicating With Plan Participants
Chapter 3 Pharmacy Benefit Plan Design
Carve-In Versus Carve-Out
The Plan Design Process
Cost Management
Cost Sharing
Copays and Cost-Sharing Subsidies
Plan Limitations, Restrictions and Exclusions
Claims Processing and Administration
Monitoring and Evaluation
Questions to Ask a Plan Provider
Chapter 4 Practice Guidelines and Outcomes Research
Types of Guidelines
Guideline Development
Outcomes Research and Pharmacoeconomics
Questions to Ask About Practice Guidelines and Outcomes Research
Chapter 5 Formularies and E-Prescribing
Types of Formularies
Formulary Drug Selection
Formulary Publication
Managing and Enforcing the Formulary
Formulary Enforcement
How Formularies Reduce Prescription Drug Spending
E-Prescribing
Questions to Ask About Formularies
Chapter 6 Drug Utilization Review
The History of Drug Utilization Review
The Basics of Drug Utilization Review
Timing
The Importance of Drug Utilization Review
The Downside of Drug Utilization Review
Utilization Reports
Questions to Ask About Drug Utilization Review
Chapter 7 Promoting Compliance
Why Patients Don't Comply
Encouraging Patient Compliance
Encouraging Prescriber Compliance
Compliance Education Programs
Questions to Ask About Patient and Provider Compliance
Chapter 8 Pharmacies, Pharmacy Networks and Pharmacy Reimbursement
Delivery Options for Outpatient Pharmacy Services
Contracted Networks
In-House Pharmacies
Company Pharmacies
Mail-Service Pharmacies
Online Pharmacies
Specialty Pharmacies
Integrated Delivery Systems
Medication Therapy Management
Pharmacy Reimbursement Methods
Product Cost Plus Dispensing Fee
Capitation and Risk Sharing
Usual and Customary Charges
Incentive Payments
Payment for Medication Therapy Management Services
Evaluating Reimbursement Methods
Claims-Processing and Point-of-Sale (POS) Technology
Defining and Monitoring Pharmacy Quality
OBRA '90 Requirements
Performance Criteria
Participant Satisfaction Surveys
Questions to Ask About a Pharmacy Network
Chapter 9 Evaluating and Selecting a Pharmacy Benefit Manager
The Stakeholders
How PBMs Manage Prescription Drug Costs
How PBMs Are Paid Choosing a PBM
Requesting Information and Proposals
The PBM Contract
Transparency
Specialty Medications
Evaluating PBM Performance
Questions to Ask When Selecting a PBM
Chapter 10 Prescription Benefits in Public Sector and Government Programs
Medicare
Medicaid
Children's Health Insurance Program (CHIP)
Workers' Compensation
Questions to Ask Workers' Compensation PBMs
Glossary
Index