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Pharmacist Opportunities Within a Pharmacy Benefit Manager PowerPoint Presentation

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Description : This presentation on Pharmacist Opportunities within a Pharmacy Benefit Manager was created by the School of Pharmacy Relations Committee for AMCP. This presentation tries to describe the key components of a medication therapy management Part D program, list the current eligibility criteria and program requirements and discuss the value of medication therapy management programs within health care and the role of the pharmacist.

Tags : Managed Care Pharmacy, healthcare, Academy of Managed Care Pharmacy, pharmacists, Managed Care Organizations, Student Pharmacist, Medication Therapy Management, Part D, Prescription Drug, Benefit, Pharmacy Benefit Manager

Published on : Jul 01, 2020 | Views : 1268 | Downloads : 1

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Slide 1-

Pharmacist Opportunities Within a Pharmacy Benefit Manager Created by the School of Pharmacy Relations Committee for AMCP Updated: February 2020
Slide 2-

What PBMs do for Plan Sponsors Administer pharmacy benefit and plan design Retail, mail, specialty Develop, contract and administer various pharmacy networks such as retail, long term care and home infusion (payment, reporting, auditing), mail order and/or specialty PBMS own/operate mail service and specialty pharmacies Provide decision support for prescribing and utilization Prior authorization Quantity limits Step Therapy
Slide 3-

What PBMs do for Plan Sponsors Manage formularies Contract with pharmaceutical manufacturers Offer Medication Therapy Management (MTM) Offer health and wellness programs Disease management Health risk assessments Smoking cessation Design and offer other unique clinical programs (i.e., Adherence, Oncology Management, Specialty)
Slide 4-

Who PBMs Serve Corporate health plans Health plan organizations Insurance groups Blue Cross Blue Shield plans Government entities (federal, state, local) Taft Hartley/unions Third-party administrators Discount card/cash card programs Medicare Part D individuals
Slide 5-

Pharmacy Student Opportunities Internships Pre-graduation Project-based summer positions Varying length and locations Residencies One-year postgraduate training Development of advanced knowledge and skills distinct to the PBM environment Varying locations Multiple residencies across the country listed at www.AMCP.org
Slide 6-

Pharmacist Opportunities Clinical Operations Administration/Corporate
Slide 7-

Pharmacist Opportunities Clinical – Benefit Design Integrated Pharmacy/Medical Benefit Patient is responsible for 100% until COMBINED medical/pharmacy deductible is met Preventative drug coverage Cost share incentives Higher or lower cost share based on perceived value of drug category Medications used to treat chronic conditions (e.g. asthma, diabetes, high cholesterol) Medications where over the counter options exist (e.g. proton pump inhibitors, non-sedating antihistamines)
Slide 8-

Pharmacist Opportunities Clinical – Formulary Formulary Management Formulary or Preferred list of drugs created to provide treatment options for a wide variety of diseases and conditions in the outpatient setting Tool to save plan sponsors and members money through the promotion of generics and preferred brand medications Clinical input provided by Pharmacy & Therapeutics Committee (P&T)
Slide 9-

Pharmacist Opportunities Clinical – P&T Pharmacy & Therapeutics Committee (P&T) Usually comprised of physicians and pharmacists Meets regularly to review newly available drug therapies, treatment options, and changes in clinical guidelines Responsible for clinical composition of formularies Also involved with: Developing and maintaining coverage criteria Reviewing and approving the clinical basis for the components of individual programs and services designed to affect drug utilization (e.g. prior authorization, step therapy)
Slide 10-

Pharmacist Opportunities Clinical – Clinical Programs Utilization management Prior authorization Coverage of drug dispensed based on pre-defined criteria Trial of alternative therapy may be required (step therapy) Quantity limits Coverage for amount of drug dispensed Limitations may be defined by category or individual drug
Slide 11-

Pharmacist Opportunities Clinical – Clinical Programs Patient safety Concurrent drug utilization review Alerts presented at the point of dispensing Require pharmacist review Can incorporate medical data Retrospective drug/diagnosis utilization review Alerts presented after a prescription has been dispensed Can incorporate medical data Typically physician review Option for patient notification
Slide 12-

Pharmacist Opportunities Clinical – Clinical Programs Patient safety (continued) Fraud/abuse prevention Review of key drug classes for patterns of inappropriate use Personalized medicine Use of genomic testing for drug and strength selection Health and wellness Disease management Health risk assessment and biometric screenings
Slide 13-

Pharmacist Opportunities Clinical – Benefit Design Channel management/patient management Retail Acute and maintenance use medication Smaller day supply e.g. 30 days Mail Maintenance medication Chronic conditions Larger day supply e.g. 90 days Specialty Medications that are high cost with complex dosing requirements Variations in day supply
Slide 14-

Pharmacist Opportunities Operations Call center pharmacists and Management Respond to member, provider and pharmacy questions/concerns regarding drug therapy Mail service pharmacists and Management Process prescriptions mailed in by plan participants Perform DUR and other utilization management programs Fill prescriptions Logistics/operations Workflow, inventory, and personnel management
Slide 15-

Pharmacist Opportunities Corporate Account management – consultative, day-to-day management of clinical offerings to client base Clinical program development – create and manage utilization management programs before they are implemented and managed by pharmacists Drug Information – provide internal and external customers with pertinent drug data Rebate Management – contracting with manufacturers Network Management – support network design and contracting
Slide 16-

Pharmacist Opportunities Corporate/Administrative Specialty Products – management of high cost, high touch product offering Informatics – support client reporting and complex database analysis Product development – ongoing support to variety of client offerings, both internally and externally Marketing – support corporate initiatives to promote the organization Outcomes – support pharmacoeconomic analysis Regulatory/Compliance – support PBM in regulatory affairs and compliance aspects
Slide 17-

Advancement Opportunities Opportunities: Supervisor Manager Director Vice President President Areas of the PBM: Retail Services Specialty Pharmacy Mail Pharmacy Therapy/Disease Management Marketing Client Management Utilization Management Regulatory/ Compliance
Slide 18-

Thank you to AMCP member Jeff Larson for updating this presentation for 2020.
Slide 19-

To improve patient health by ensuring access to high-quality, cost-effective medications and other therapies. Mission & Vision

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