MEDICATION THERAPY Management (MTM) services introduced in 2006 under Medicare Part D have prompted pharmacists to adopt expanded roles in the commercial setting, such as performing a comprehensive medication review and monitoring a patient's response to therapy. One of the main caveats, however, is the lack of standardized reimbursement for pharmacists' services.
Pharmacy Best Practices
Groups such as WellPoint are turning specialty pharmacy into a highly beneficial business model for everyone from the non-clinician to physicians.
What works for retail pharmacy patients should work for mail-order recipients, namely, personalized drug counseling. When consumers pick up their prescriptions at a local pharmacy, they have access to pharmacists who can advise them on how and when to take medications, warn them of potential side effects and discuss generic alternatives.
Pharmacy Benefits Managers (PBMs) have long gotten a bad rap, taking heat for lack of transparency in their dealings with pharmaceutical manufacturers. Some agreements leave health plans in the dark about the true value of their PBMs. Touting benefits, from clinical-based formularies and lower drug costs and to specialty pharmacy benefits and retail networks, may not be enough today to attract business in a competitive marketplace.
When a drug is approved by FDA, there is a large volume of data available for review, but once the drug is being used in the market, new safety data are not as forthcoming, according to Gerald J. Dal Pan, MD, director, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research (CDER), U.S. Food & Drug Administration (FDA).
THE ADVENT OF COSTLY biologic drugs for psoriasis hasn't inspired the inappropriate prescriptions many MCOs expected. But that's largely because MCOs are employing a firm hand in managing these drugs early on, educating providers and patients before new drugs come to market and implementing prior authorization (PA) requirements that balance patient access with cost effectiveness. While some policies occasionally require tweaking, sources agree that physicians are not taking these prescriptions lightly.
Not designed to be used as a stand-alone formulary, reference formulary systems offer a baseline for employers to use to compare their current formulary with one optimized to achieve maximum cost savings and to maintain quality.
A value-based formulary takes into account individual illnesses and varies financial incentives determined by how important a medication is to a patient.