NAPSRx Certification Exam Study Guide Chapter 13

CDHP stands for? pg 179 - Consumer-Directed Health Plan The two hallmarks of CDHP are? pg 179 - 1) greater cost sharing by consumers, 2) consumer choice and consumer accountability have greatly increased in importance Who are the dominant type of health insurance providers in the U.S.? pg 180 - MCO (managed care organizations) Almost what percent of employed Americans are now covered by HMO's, PPO, or a point of service plan? pg 180 - 80% About what percent of MCO use formularies? pg 180 - 90% Is a list of prescription drugs approved by insurance coverage? pg 180 - Formulary Drugs are selected for the formulary principally on the bases of? pg 180 - Therapeutic value Side Effects Cost Formularies range in restrictiveness how? pg 180 - Open - both listed and non-listed drugs reimbursed closed - only listed drugs reimbursed This program involves retrospective monitoring of physicians prescribing patterns, however intense cost pressures in the managed-care environment have threatened to change the focus of this program from quality and patient safety to cost savings? pg 181 - DUR (Drug Utilization Review) The history of drug formularies extends all the way back to what point of U.S. history? pg 181 - Revolutionary war What types of tools does an MCO use to achieve its clinical and cost objectives? pg 181/182 - generic prescribing generic and therapeutic substitution point-of-service edits step therapy non-formulary exception procedures limits on quantity, cost and refill frequency Variable (tier copayments designation of preferred products restrictions according to physician specialty NDC (national drug code) blocks