What is Managed Care

Pharmacy?
Developed by AMCP
Membership Committee 201415
Updated: February 2016

Agenda
Introduction to AMCP
Managed Care Pharmacy Overview
Roles of Pharmacists in Managed Care
Pharmacy
AMCP Student Pharmacist Membership

2014 Academy of Managed Care Pharmacy

INTRODUCTION TO AMCP

 Vision Statement
Managed care pharmacy improving health care
for all

Mission Statement
Empower its members to serve society by using
sound medication management principles and
strategies to improve heath care for all

2014 Academy of Managed Care Pharmacy

MANAGED CARE
PHARMACY OVERVIEW

Goals of Managed Care

Prevention of disease
Focus on wellness and enhanced
quality of life
Improved clinical outcomes
Quality and accessibility of health
care
Cost containment

2014 Academy of Managed Care Pharmacy

What is Managed Care Pharmacy?

Managed care pharmacy focuses on
managing medication specific outcomes in a
way that drives down the total cost of care
and improves the overall wellbeing of the
patient.
Managed care pharmacy organizations cover
populations of people pharmacists in
managed care pharmacy have the ability to
impact the care of millions of patients.

2014 Academy of Managed Care Pharmacy

The Players in Managed Care

Pharmacy

2014 Academy of Managed Care Pharmacy

Physician Payment Types

Type of Reimbursement
Mechanism

Fee-for-service
Pay-for-performance

Bundled payments

Shared savings
Limited or partial risk
Full capitation

2014 Academy of Managed Care Pharmacy

Definitions
Physicians are paid for each service they provide to a patient.
In a pay-for-performance (P4P) environment, physicians
receive compensation or bonuses if they meet certain metrics
for quality and efficiency. Creating quality benchmark metrics
ties physician reimbursement directly to the quality of care
they provide.
The plan reimburses the physician on the basis of expected
costs for that particular episode of care or treatment
services, encouraging physicians to manage costs and meet
high-quality care standards.
Provides incentives for physicians with respect to specific
patient populations. A percentage of any net savings realized
is shared with the physician.
Includes both the gain share potential of an upside model, but
also the downside risk of sharing the excess costs of
healthcare delivery between physician and payer.
Patients are assigned a per member per month (PMPM)
payment based on their age, race, sex, lifestyle, medical
history, and benefit design. Payment rates are tied to
expected usage regardless of whether the patient visits more
or less. Like bundled payment models, physicians have an
incentive to help patients avoid high-cost procedures and
tests in order to maximize their compensation.

Pharmacy Payment Types

Type of Reimbursement
Mechanism

Definitions

AWP- Average Wholesale

Price
WAC-Wholesale
Acquisition Cost

The average price that a pharmacy pays to a wholesaler for

drugs.

AMP-Average
Manufacturers Price

The average price a wholesaler pays to a manufacturer for

drugs distributed to retail pharmacies.

NADAC- National
Average Drug
Acquisition Cost

CMS pricing benchmark based on average invoice costs that

pharmacies pay for Medicaid outpatient drugs.

The price a wholesaler pays to a manufacturer for drugs, or

what a pharmacy pays when buying direct.

MAC-Maximum Allowable The maximum amount paid to a pharmacy for a listed generic
drug, no matter what ingredient cost is submitted.
Cost

FUL-Federal Upper Limit

2014 Academy of Managed Care Pharmacy

The maximum amount paid to a pharmacy for a listed generic

drug, no matter what ingredient cost is submitted. Formerly
known as HCFA MAC

Managed Care Pharmacy Tools

Formulary development with P & T
Committees
Medication Therapy Management
Prescription Drug Monitoring programs
Drug Utilization Review
Utilization management: prior authorizations,
quantity limitations, and step therapy
Preferred & exclusive networks
Mail order pharmacy
Specialty pharmacy

2014 Academy of Managed Care Pharmacy

www.amcp.org/mcptools

ROLES OF PHARMACISTS
IN MANAGED CARE
ORGANIZATIONS

Pharmacists in Managed Care

Pharmacy
Over 18,000 pharmacists working
for health plans and pharmacy
benefit management companies
Ensure the pharmacy benefit
plan provides individual patients
with medications that are:
Clinically appropriate
Cost-effective
Delivered through the appropriate
channel

2014 Academy of Managed Care Pharmacy

Drug Distribution and Dispensing

Pharmacists manage drug distribution
process through four different approaches:
Community Pharmacies MCOs contract
with broad-based networks of
participating pharmacies
Manage the pharmacy network
Perform drug utilization reviews (DUR)

Managed Care Organization Operated

Pharmacies
In-house pharmacy owned by the managed
care organization to provide enhanced
pharmaceutical services

2014 Academy of Managed Care Pharmacy

Drug Distribution and Dispensing

Mail Order and Online Services
Some Managed Care Organizations own or
contract with mail order pharmacies
Manage services to ensure quality

Collaboration with physicians and other

healthcare professionals
Work with prescribers to ensure the medications
prescribed are:
Eligible for Coverage
Clinically Appropriate
Cost Effective

2014 Academy of Managed Care Pharmacy

Patient Safety
Pharmacists help ensure patient
safety by:
Analyzing prescription claims
Reviewing prescription use patterns
Educating prescribers about best
practices

2014 Academy of Managed Care Pharmacy

Patient Safety Programs/Tools

Drug Utilization Review (DUR)
programs identify potential
prescription-related problems

Drug/drug interactions
Duplication of therapy
Known allergies
Under- or overdosing
Potentially inappropriate therapy

2014 Academy of Managed Care Pharmacy

Patient Safety Program/Tools

Fraud and Abuse Programs
Review key drug classes
Monitor for patterns of inappropriate use

Prior Authorization (PA or Prior

Auth) Programs
Approval process to encourage proper use
of medications
Discourages inappropriate prescribing of
medications

2014 Academy of Managed Care Pharmacy

Patient Safety Programs/Tools

Monitoring Programs
Lab-based monitoring
Ensure medications are prescribed safely and
used appropriately
Assess response to therapy

Monitor medication adherence

Screen for potential fraud, waste, and
abuse
Promote optimal patient outcomes

2014 Academy of Managed Care Pharmacy

Clinical Program Development

To enhance patient care, particularly
for those with chronic conditions,
pharmacists design clinical programs
to:
Use evidence-based research data to create
disease-management and medication
therapy management programs
Encourage appropriate prescribing and
proper use of medications
Promote use of cost effective therapies to
benefit both patients and payers
Improve health and quality of life for
population under their care

2014 Academy of Managed Care Pharmacy

Communication with Patients, Prescribers, and

Pharmacists

Pharmacists design and use

communication protocols to facilitate
exchange of necessary information:
Notify prescribers of drug safety alerts and
prior authorization requirements
Educate patients on their disease state
and medications
Provide pharmacies information regarding
benefit parameters

2014 Academy of Managed Care Pharmacy

Plan Benefit Design

Pharmacists collaborate with other
healthcare professionals to design
effective benefit structures that serve
a populations needs:

Formulary
Plan Design
Pharmacy network
Utilization management
Patient cost share
Use of generic drugs

2014 Academy of Managed Care Pharmacy

Business Management
Pharmacists contract with employer
and health plan clients, pharmacies,
and manufacturers to structure
business arrangements that:
Allow their clients to customize clinical and
reporting requirements
Negotiate with manufacturers for
discounts on drug prices
Establish networks of pharmacies

2014 Academy of Managed Care Pharmacy

Cost Management
Pharmacists help their clients
(employers, HMOs, trust funds,
Medicaid, etc.) evaluate and improve
their pharmacy benefit:
Encouraging providers to prescribe cost
effective treatments
Integrating improvements with healthcare
delivery
Introducing system interventions
Using data to identify adherence and nonadherence
Ensuring a scientific evaluation of cost

2014 Academy of Managed Care Pharmacy

AMCP STUDENT
PHARMACIST
MEMBERSHIP

Membership Advantages
General Membership Benefits
Valuable Resources
Access to the Journal of Managed Care & Specialty
Pharmacy (JMCP) and www.amcp.org
Daily Dose email news briefings
Monthly Webinars

Nexus and Annual Meeting & Expo

Student Pharmacist Benefits

Student pharmacist-specific programming
Conferences
Webinars

Managed Care Pharmacy Residency Showcase

Student Pharmacist Resource Center:
www.amcp.org/studentcenter

2014 Academy of Managed Care Pharmacy

Opportunities with your local chapter

Get involved with your AMCP

Student Pharmacist chapter!!
Participate in chapter programs,
activities, and committees
AMCP Foundation P&T
Competition
Networking and Professional
Events
Chapter specific events
Serve as an elected chapter officer

2014 Academy of Managed Care Pharmacy

Student Involvement Varies by Year

Attend events hosted by your AMCP student
pharmacist chapter
1st
year Volunteer for an AMCP Chapter committee

2
year
nd

3
year
rd

Run for chapter officer

Apply for Managed Care Summer Internships
Participate in the AMCP Foundation P&T Competition
Apply for national AMCP Committees

Attend AMCP Nexus Managed Care Pharmacy

Residency Showcase to find a managed care residency
4th
year program

2014 Academy of Managed Care Pharmacy

How to Make the Most of Your Membership

Network,
Network,
Network
Be There!

Volunteer

2014 Academy of Managed Care Pharmacy

Start collecting business cards!

Build a relationship with your local
AMCP Diplomat
Contact local Managed Care
Pharmacy Professionals
2 National Meetings - AMCP Nexus
and Annual Meeting & Expo
Student-specific educational sessions
and webinars
Local student pharmacist run
conferences
AMCP chapter opportunities
No chapter? Create one!
National AMCP Volunteer and
Committee Opportunities

THANK YOU!
Special thanks to AMCP Past-President Gene Reeder, AMCP
Staff Betty Whitaker and Susan Noell, and the Membership
Committee Members: Barbara Hamer, Carrie Armstrong,
Donna Bell, Jasmine Knight, Karen Goolsby, Kim Forester,
and Vimal Reddy

Thank you to AMCP

member Nisreen
Shamseddine for
reviewing this
presentation for 2016.