Managed Care Pharmacy Practice

Managed Care Pharmacy Practice, Second Edition offers information critical to the development and operation of a managed care pharmacy program. The text also covers the changes that have taken place within the delivery of pharmacy services, now that a higher percent of the population is enrolled in some type of "managed" health care organization. The Second Edition reflects contemporary health care management and policy issues, details how the value of pharmaceuticals is assessed by health plans and PBMs, and discusses how value-based formularies are developed and managed. Health care policy issues are addressed from a societal perspective to illustrate how managed care organizations respond to, or lead, public policy decisions. The Second Edition has been thoroughly updated to reflect the significant changes in development and execution of managed care pharmacy benefit management.

The Second Edition includes a glossary, as well as new chapters and extended topics in:

• Drug Dossier Development and Applications
• Self-funded pharmacy benefit management
• Contracting with pharmaceutical manufacturers
• The impact of HIPAA on pharmacy benefit management
• Healthcare Benefits from the Employer Plan Sponsor Perspective
• Value of Pharmaceuticals
• Medicare Part D
• Public Policy and Managed Care Pharmacy
• AMCP Format for Formulary Submission
• Pharmaceutical contracting with MCOs and PBMs
• Medical Therapy Management Programs (MTMPs)
• Pharmacy & Therapeutics Committees in Managed Care Operations
• Drug Formularies
• The role of employer groups in pharmacy benefit development and management
• "Specialty pharmacy:" the new pharmacy benefit management developed to cover injection-based biologicals created by pharmaceutical manufacturers
• The complex pharmacy benefit design options available today
• Implementing MTMPs as a basis for developing the next generation of clinical pharmacy programs to support disease management

Table of Contents

Chapter  1  The Role of Managed Care in the US Health Care System
Chapter  2  Overview of Prescription Drug Benefits Managed Care
Chapter  3  Pharmacy Benefit Design, Marketing, and Customer Contracting 
Chapter  4  Pharmacy Benefit Management Programs
Chapter  5  Pharmacy Distribution Systems and Network Management 
Chapter  6  Specialty Pharmaceuticals
Chapter  7  Managed Care Information Systems
Chapter  8  Drug Utilization Review Strategies
Chapter  9  The Role of Drug Formularies in Managed Care Organizations
Chapter  10  Member Satisfaction Strategies
Chapter  11  The AMCP Format for Evidence Based Formulary Submissions
Chapter  12  Pharmacoeconomic Research and Applications in Managed Care
Chapter  13  Pharmacy & Therapeutics Committees in Managed Care Organizations
Chapter  14  Role of the Pharmaceutical Company in Managed Care
Chapter  15  Managed Care Contracts with Pharmaceutical Manufacturers
Chapter  16  Impact of Managed Care on Pharmacy Practice
Chapter  17  The Fundamentals of Healthcare Benefits from the Employer Plan Sponsor Perspective
Chapter  18  Medicaid Pharmacy Benefit Management
Chapter  19  Medicare Pharmacy Benefits
Chapter  20  The Value of Pharmaceuticals
Chapter  21  Pharmacist Career Opportunities in Managed Care
Chapter  22  Ethical Aspects of Pharmacy Practice in Managed Care
Chapter  23  Politics, Public Policy and National Health Care Reform: Medicare and the Medicare Modernization Act of 2003
Chapter  24  International Opportunities for Pharmacists in Managed Care
Chapter  25  Future of Managed Care Pharmacy Practice

About the Author(s)

Robert P. Navarro, PharmD

Robert Navarro consults to pharmaceutical companies, the managed care industry, and the legal profession on managed prescription drug benefit reimbursement, health economic outcomes applications, drug contracting, benefit design, and pharmaceutical marketing issues. He qualified for his B.S. and Doctor of Pharmacy degrees at the University of Minnesota College of Pharmacy. He has practiced in acute care, community pharmacy, long-term care, and managed care.

He began his managed care career in 1983 with United HealthCare (UHC), where he wrote UHC’s first drug formulary and initiated the first brand drug rebate contracting program. While a pharmacy director at UHC, he was involved in the creation of the PBM Diversified Pharmaceutical Services (DPS), now part of Express Scripts, Inc. (ESI). While in Minnesota, Navarro also served as pharmacy director of Physicians Health Plan (now Medica). He developed and operated the pharmacy program at Health Net in California where he was a Vice President of Provider Services. Navarro was also Vice President, Pharmacy & Therapeutics at Express Scripts, Inc., before beginning his consulting practice twelve years ago.