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4. Generic utilization rate: It can be calculated by Closed formulary is an exclusive list of specific drugs
dividing the total number of generic prescription that may be covered under the health plan. This
claims dispensed by the total number of formulary restricts prescribers from prescribing
prescription claims. The percent of generic is always drugs outside of the formulary. Drugs that do not
less than 100 since there are always patent- appear on the list of approved products are defined
protected brand names on the market. as non-formulary drugs and are not covered by
health plans or PBMs. A patient needs to pay out of
A percent generic utilization rate is affected by the his own pocket in order to get non-formulary drugs.
following factors:
Limited, restricted, intermediate, partially closed, or
1. Pharmacists. selectively closed formularies are formulary hybrids.
2. Prescribers. They restrict or limit the prescriber choices in
3. Advertising. certain therapeutic categories and offer unlimited
4. Co-payment fee structure of health plan. choices within the remaining drug classes. An
example of such a drug would be Finasteride for the
5. Percent DAW prescriptions: It is the total treatment of male pattern baldness. A healthcare
number of prescriptions dispensed with DAW or plan may opt out the whole category from the
“Dispensed As Written” divided by the total prescription plan.
prescription claims.
Negative formulary includes a list of drugs that
A percent DAW is affected by the following factors: cannot be prescribed within a specific therapeutic
class.
1. Prescribers.
2. Co-payment fee structure of health plan. 44.(d) All. Manage care prescription plans are
3. Patients’ psychology. reimbursed through the following methods:
6. Percent formulary compliance: It can be 1. Capitated reimbursement method.
calculated by dividing total number of prescriptions 2. Fee-for-service reimbursement method.
filled by using a formulary by the total number of
prescription claims. 1. Capitated reimbursement method: As discussed
earlier, under this type of reimbursement method, a
A percent formulary compliance rate is affected by pharmacy will receive a fixed monthly fee for the
the following factors: number of members associated with the plan
regardless of services. Under a capitated plan, a
1. Prescribers’ incentive if they follow formulary. pharmacy will receive a reimbursement from two
2. Pharmacists’ incentive if they follow formulary. major sources:
42.(b) The abuse of prescription drugs in the United 1. A fixed monthly capita rate per plan member.
States is on the rise and has a dramatic impact on 2. Co-payment fee prescription dispensing.
society in a multi-factorial way.
Under Capitated reimbursement plan, pharmacies
43. (a) Open formulary covers almost all are getting fixed monthly premiums from plan
medications that are available in the market. sponsors and therefore they have less incentive to
Physicians who follow the open formulary can fill unnecessary prescriptions. This may help the
prescribe virtually any drug. Payers or plan plan sponsors cut down and control the prescription
members need to pay higher premiums due to costs.
freedom of choice.
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