Does the MCO offer prescription drug and behavioal benefits

Does the MCO offer prescription drug and behavioal benefits and what are the terms?

Solution

An MCO is able to provide drug benefit coverage based on payments from two sources: - Plan sponsors that pay a pre-determined amount per month as a premium for drug coverage insurance or reimburse for individual prescription costs, and - Patients who pay a portion of the cost of the benefit through co-payments, coinsurance, and deductibles.

The goal of managed care organizations\' drug coverage programs is to provide appropriate, affordable and accessible prescription drug benefit coverage so that positive patient outcomes are achieved. The challenges in meeting this goal, however, are numerous and complex. Managed care drug benefit coverage programs routinely use a variety of tools and strategies, frequently in tandem, to achieve the goal of managing costs for consumers and plan sponsors, including:

- Establishing formularies or preferred drug lists so that purchasing resources can be concentrated on making appropriate drugs available to most MCO members, while allowing for medically necessary alternatives for selected patients.

- Negotiating volume discounts and implementing maximum allowable cost (MAC) pricing with retail and mail order pharmacies to provide MCO members with convenient access to pharmaceuticals

- Working with prescribers to ensure they are using drugs appropriately based on sound scientific evidence and principles

- Promoting the use of appropriate generic products. Such generics must be determined by the Food and Drug Administration (FDA) and/or the MCO to be as safe and effective as the original product and interchangeable with it. Most MCOs structure their prescription drug coverage to promote the use of generics because they usually offer greater value

- Implementing disease management and medication therapy management programs designed to improve the quality and efficiency of patient care

- Implementing medication evaluation policies and systems such as drug utilization review, prior authorization and quantity and dosage management to ensure high quality, medically safe and effective therapy and cost efficient use of prescription drugs

- Negotiating contracts with pharmaceutical manufacturers to obtain lower drug prices

References:

http://www.amcp.org/WorkArea/DownloadAsset.aspx?id=9299