Benefit plan , pharmacy

Pharmacies have third-party patients and private-pay patients. Private-pay patients, sometimes referred to as cash patients, are people who do not have any health insurance coverage or people who have health insurance that does not cover prescription drugs. From the pharmacy s perspective, patients who pay the pharmacy directly for their prescriptions and later are reimbursed by their insurance company often are indistinguishable from private-pay patients. This type of prescription drug insurance, called indemnity insurance, used to be common, but it now has been replaced largely by service benefit plans. Under a service benefit plan, the patient may pay the pharmacy a predetermined portion of the prescription cost, but the pharmacy is reimbursed directly by the third party for most of the prescription cost. 

Employee benefits include paid vacations, an employee assistant program, a pharmacy benefit plan, hearing and vision benefits, short- and long-term disability benefits, and life, medical and dental insurance plans. 

No other health care innovation or service has been held to a higher standard of evidence than the practice of pharmaceutical care. Few — if any ofher — health care professions have been required to demonstrate that their services not only improve care delivered to patients but also save money. Even when the debate over inclusion of chiropractic care services in health benefit plans transpired, it was more overwhelming public testimony rather than economic cost-savings data that persuaded third-party payers to begin covering these services. Although it is easy to say that this is unfair, fhe silver lining is that as pharmaceutical care becomes a more widely covered service, the profession of pharmacy will be well prepared to answer the call for accounf-ability of oufcomes. 

The importance of the basic plan design itself cannot be overemphasized. It does not matter whether one is creating a new pharmacy benefits plan, improving an existing one, or preparing to work with a PBM company. If the basic plan is not well thought out and tailored to a company s own needs and circumstances, it will make little difference how effective the other components of benefits management are. All the parts of PBM are interre-... 

According to fhe National Pharmaceutical Council Prescription Medicine Benefit Program Checklistf benefifs managers and fhe companies fhey represent want a pharmacy benefit plan that ... 

Plan limitations, restrictions, and exclusions typically are major cost-containment elements of pharmacy benefits plan designs. Examples include a cap or limit on outpatient drug benefits (usually 2000 a year per member), the formulary or preferred drug list, and a limit on the quantity of drugs dispensed per prescription (fhe plan pays for only a limited supply of medication af one time). The mosf common scenario is fhaf fhe plan pays for a 30-fo 34-day supply of a prescribed drug at a pharmacy. 

Vogenberg, FR and Sica, JM. Pharmacy benefit plan design. In Managing Pharmacy Benefits. Vogenberg, FR, and Sica, JM, Eds. International Foundation of Employee Benefit Plans, Brookfield, WI, 2001, chapter 3. 

Formulary systems are an essential tool used in a variety of settings including hospitals, ambulatory clinics, health plans, pharmacy benefit management companies, and government agencies. This tool, if used correctly, promotes rational, clinically appropriate, safe, and cost-effective pharmaceutical care. 

Mail-order pharmacy programs appear to be growing rapidly among employer-based health care benefit plans. In 1989, about 13 percent of U.S. employees had a mail-order drug benefit by 1990, 20 percent of employees had such a plan (135). 

Veatch, Robert M., and Amy Haddad. Case Studies in Pharmacy Ethics. Oxford Oxford University Press, 2008. The ethical issues relate to difficult decisions faced by pharmacists (rather than pharmaceutical companies). Examples of the topics covered in this book include assisted suicide, conscientious refusal, pain management, equitable distribution of drug resources within institutions and managed care plans, confidentiality, and alternative and nontraditional therapies. Another ethical issue concerns weighing costs and benefits in helping consumers choose drugs. 

Many third parties hire pharmacy benefit managers (PBMs) to provide prescription claims processing and other services. Examples of third parties that hire PBMs are insurance companies, employers, Medicare prescription drug plans, and state Medicaid programs. PBMs establish pharmacy networks as part of their claims management services, so many pharmacy third-party contracts are with PBMs. Examples of other ser-... 

It is important to recognize that mission statements and strategic plans vary among types of organizations, especially within health care. The mission statement and strategic plan of a not-for-profit children s research hospital likely will be different from that of a for-profit pharmacy chain (Table 24-1). The aspects of a professional service that will need to be emphasized in a business plan will vary as well. The not-for-profit children s research hospital may want to see how a new professional service will result in enhanced clinical outcomes or benefit the greatest number of children at the lowest possible cost. On the other... 

Sullivan SD, Lyles A, Luce B, Grigar J. AMCP guidance for submission of clinical and economic evaluation data to support formulary listing in U.S. health plans and pharmacy benefits management organizations.. Manage. Care Pharm. 2001 7 272-282. 

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