lecture 10: community pharmacy 2

medicare

insurance program administered by the federal govenrment, primarily for those 65+; also includes those with disabilities, ALS, permanent kidney failure

medicaid

insurance program for low-income people run by the states with federal oversight

PACE, PACENET

prescription assistance program for PA residents 65+ meeting income limits; funded through lottery sales

commerical insurance

insurance plans acquired thro employment or individual purchase

medicare part C

medicare advantage, combines parts A and B into a plan run by private sponsor under medicare rules, something also with drug coverage (MA-PD

medicare part B

covers physician visits, outpatient medical care, durable medical equipment, some preventative services

medicare part D

prescription drug coverage

medicare part E (medigap)

private coverage to reduce cost-sharing payments under patients's part A and B

medicare part A

covers hospital, skilled nursing facility, hospice care

extra help

provides reduced out-of-pocket drug costs for low income/low resource medicare patients

open enrollment

time period (oct 15-dec 7) annually for medicare where patients make plan choices for the following coverage year

"red, white and blue" card

provides billing info for traditional medicare part A +/- B

what does it mean to have a culture of safety?

everyone on the team will be willing and able to report mistakes w/o getting in trouble

what are the best practice for handling errors in community pharmacy?

-follow organization's policies and any state law

-assess/minimize harm to pateint

---usually notify patient and prescriber, refer for appropriate medical attention, monitor, arrange for correction of error

reporting of medical errors

-in-house error log/ reporting line, reporting to supervisor

-always document details of error and above conversations subjectively and do not jump to conclusions

external reporting agencies

institute for safe medical practices (ISMP)

food and drug administration (FDA) for possible labeling changes

how should follow-up to reporting be followed?

in a non-punitive "systems" approach

-aligns with just culture because everyone is sharing accountability to the error when it occurs

PWWR and goals of this

pharmacy workplace and wellbeing reporting

-goals are to report workplace conditions in confidential manner

who partnered to launch PWWR and who analyzes it?

APhA and NASPA partnered

-analyzed by alliance for patient medication safety

PBMS

Pharmacy Benefit Managers

They handle prescription claims processing; pushing towards mail order prescriptions

formulary mangement

decides what drugs are covered and at what price

formulary

list of what drugs are covered at the plan and at what level

step therapy

requires individuals to try less expensive medication before an expensive one

quanitity limitd

limits quanitity of drug covered to certain amount

prior authorization

requires prescriber to submit documentation justifying the need for the med before covering

4-tier formulary

tier 1: generic $

tier 2: preferred brand

tier 3: non-preferred brand $

tier 4: speciality

5-tier formulary

tier 1: preferred generic drugs

tier 2: non-preferred generic drugs

tier 3: preferred branded and generic drugs

tier 4: non-preferred branded and generic

tier 5: speciality drugs

what considerations affect formulary development and

money, clinical effectiveness (cost vs benefits)

examples of prior authorization documentation requirments

-previously tried alternatives and patient response

-unique clinical circumstances

-attestation that its being prescribed for FDA approved/ evidence based use

NCPDP D.O format

method of prescription claim transmission

(reasons for recieving DUR messages

3 categories of DUR codes

1: allergies

2: drug-drug or drug-disease interactions

3: adherance info (over/under utilization)