Managed Care Pharmacy Tools

Disparities in Medication Use and Access

Policy 2101

02/22/2022 Introduced

AMCP stands against racial and health care injustice. AMCP acknowledges that health care disparities occur across a multitude of factors, including race, ethnicity, and socioeconomics. To increase health care access for all, it is imperative to collect, evaluate, and incorporate data on race, ethnicity, and socioeconomic factors and evaluate the association of these factors on medication use and access. In addition, these factors should be considered when implementing interventions, developing benefit offerings, and designing formularies.

AMCP supports the development and training of managed care pharmacists and other health care professionals, students, and educators in diversity and inclusion practices to ensure that equitable access to quality care is available to all patients, both in clinical programs and overall care.

Drug Use Evaluation

Policy 9909

11/01/1999 Introduced
03/01/2004 Reapproved
12/01/2008 Reapproved
10/01/2012 Reapproved

02/08/2017 Reapproved

AMCP recognizes the value of drug use evaluation (DUE) as a means of improving the quality of patient care, enhancing therapeutic outcomes, and reducing inappropriate pharmaceutical expenditures, thus reducing overall health care costs. Using DUE information, managed care pharmacists can identify prescribing trends in patient populations and initiate corrective action to improve drug therapy for groups of patients, as well as individuals.

(See AMCP Concepts in Managed Care Pharmacy – Drug Use Evaluation)

Formularies

Policy 9910

11/01/1999 Introduced
02/01/2005 Revised

02/01/2010 Reapproved

02/08/2017 Revised

04/23/2018 Revised

03/25/2019 Revised

AMCP supports the use of appropriately designed formularies as quality-enhancing, cost-effective pharmaceutical care tool that meets the needs of the patient population and assist members of the health care team in effectively managing a patient's total medical care regimen. Formulary coverage decisions are based primarily on sound clinical evidence. Cost should be considered only after safety, efficacy, therapeutic need and patient outcomes have been assessed. The value of a formulary is maximized when it is part of an integrated patient care process and integrates with other health care management tools, such as drug utilization review and medical treatment guidelines. The overall formulary system encourages physicians, pharmacists, and other care givers to work together to ensure positive outcomes and cost-effective results.

(See AMCP Managed Care Pharmacy Practice Positions - Formularies, and AMCP Concepts in Managed Care Pharmacy - Formulary Management)

Off-Label Use of Pharmaceuticals

Policy 9916

11/01/1999 Introduced
02/01/2003 Revised
02/01/2008 Reapproved
10/01/2012 Reapproved

02/21/2021 Revised

AMCP supports off-label use of FDA-approved products when medically appropriate and necessary, but opposes government-mandated coverage of specific pharmaceuticals and related products, whether for FDA-approved or off-label uses. AMCP supports having managed care organizations and third-party payers consider the following criteria before deciding whether to provide coverage of FDA-approved products for certain off-label uses:

• The product has been proven effective and accepted for the treatment of the specific medical condition for which it has been prescribed according to the current edition of nationally recognized compendia, including American Hospital Formulary Service - Drug Information® (AHFS-DI®), Thomson Micromedex DRUGDEX®, Clinical Pharmacology, or the National Comprehensive Cancer Network (NCCN) Drug and Biologics Compendium™.

• The product is recommended specifically for the condition, and has been proven to be safe and effective for that condition according to reproducible formal clinical studies, the results of which have been published in peer-reviewed evidence-based medical literature. Randomized controlled trials are preferred over observational research or case studies.

 
(See AMCP Managed Care Pharmacy Practice Positions - Off-Label Use of Pharmaceuticals and Related Products)

Pharmacist's Role in Formulary Management

Policy 9922

11/01/1999 Introduced

03/01/2004 Revised

12/01/2008 Revised

10/01/2010 Reapproved

04/12/2021 Revised

AMCP supports the use of an appropriately designed formulary as a quality-enhancing, cost-effective pharmaceutical care tool that meets the needs of the patient population and assist members of the health care team in effectively managing a patient's total medical care regimen. AMCP further recognizes that pharmacists are key to the success of formulary management. Pharmacists determine the P&T Committee agenda; analyze and disseminate scientific, clinical, and health economic information for P&T Committee member review; follow-up with research when necessary; and communicate P&T Committee decisions to health plan prescribers, other health care professionals, and patients.

 
(See AMCP Managed Care Pharmacy Practice Positions- Formulary Management and AMCP Where We Stand Position Statement - Formularies)

Therapeutic Interchange

Policy 9928

11/01/1999 Introduced
03/01/2004 Reapproved
12/01/2008 Reapproved
10/01/2012 Revised

03/25/2019 Revised

AMCP supports the use of evidence-based therapeutic interchange programs as a part of a comprehensive approach to quality, cost-effective patient care. AMCP believes that therapeutic interchange may improve the patient's access to more affordable health care and represents an efficient use of pharmaceutical resources that helps keep medical costs down. The therapeutic interchange programs are designed to work in conjunction with other tools that health care professionals use to promote quality medical outcomes, and increase affordability to patients and payers. Therapeutic interchange is not always about simply lowering the medication costs; however, therapeutic interchange frequently occurs when overall health care savings can be achieved. There are instances where replacing one drug with a more costly drug may result in fewer treatment failures, better patient adherence to the treatment plan, fewer side effects, and improved clinical outcomes, which could result in lower overall health care spending.

(See AMCP Managed Care Pharmacy Practice Positions - Therapeutic Interchange)

Best Practice Principles

Policy 0002

02/01/2000 Introduced
02/01/2005 Reapproved
11/01/2009 Revised

Development of Performance Measures

Policy 0006

02/01/2000 Introduced
02/01/2005 Revised
11/01/2009 Revised

02/21/2018 Revised

Patient Adherence and Persistence

Policy 0115

11/01/2001 Introduced
02/01/2006 Revised
12/01/2010 Revised

04/07/2015 Revised

Utilization Management

Policy 0401

02/01/2004 Introduced
12/01/2008 Reapproved
10/01/2012 Revised

02/08/2017 Revised

AMCP supports the role of utilization management in the provision of quality, cost-effective prescription drug benefits. The fundamental goal of utilization management is to promote the appropriate and cost-effective use of medications. Pharmacists in all practice settings must work collaboratively to develop specific policies and procedures to ensure that the utilization management process is administered in the most efficient manner possible, is fully compliant with statutory and regulatory requirements and provides members, pharmacists and prescribers with an evidence-based, rational process to promote appropriate drug use. Examples of utilization management strategies used within a prescription drug benefit include prior authorization, step therapy, quantity management, drug utilization review (DUR), site of service steerage, and the formulary exception process.

(See AMCP Concepts in Managed Care Pharmacy – Prior Authorization).

Pharmacy & Therapeutics (P&T) Committees-Advisory Role

Policy 0602

02/01/2006 Introduced
12/01/2010 Reapproved

Mail Service Pharmacies

Policy 1202

12/01/2012 Introduced

02/21/2021 Revised

AMCP believes that managed care organizations (MCOs) must have the flexibility to utilize mail service delivery of prescription drugs as a component of their prescription drug benefit. Mail service pharmacies are a valuable tool used by MCOs to increase patient safety, offer patient convenience, and maintain the affordability of the prescription drug benefit. Additionally, MCOs should have the ability to set patient cost-sharing levels for prescription orders filled through mail service pharmacies which are different from the patient cost-sharing levels for prescription orders filled through retail pharmacies.

(See AMCP Managed Care Pharmacy Practice Positions – Mail Service Pharmacies)

Preferred Pharmacy Networks

Policy 1401

07/29/2014 Introduced

The Academy of Managed Care Pharmacy (AMCP) supports the ability of health plans to offer preferred pharmacy networks for their enrollees as a way of providing additional options and cost savings without any diminishment of quality or patient access.  Preferred pharmacy networks represent an important tool and innovation in managed care pharmacy benefits.  The Academy supports the continued use of these programs as a beneficial way to maintain quality of care, access and cost effectiveness to the pharmacy benefit.  

Regulation of the Prescription Drug Benefit

Policy 1402

10/07/2014 Introduced

04/12/2021 Revised

AMCP recognizes that government should encourage an environment in which managed care pharmacists continue to develop innovative and integrated strategies to manage prescription drug benefits for a given patient population. AMCP supports statutory and regulatory efforts that will continue to enable the ability of managed care pharmacists to consider the range of clinical, legal, quality-of-life, safety, and pharmacoeconomic factors which form the basis for the design and implementation of effective drug benefit strategies and programs. However, the Academy opposes statutory and regulatory proposals that unduly restrict the ability of managed care pharmacists from using proven tools and practices, such as drug utilization review, formulary management, utilization and network management, that are essential for the management of a prescription drug benefit. These types of proposals are objectionable if they go beyond procedural protections and enter an arena traditionally within the purview, expertise and experience of health care professionals. Unnecessary or overly burdensome regulatory restrictions could place patients at risk and increase the cost of health care. The result could compromise the availability and affordability of the prescription drug benefit.

(See AMCP Managed Care Pharmacy Practice Positions – Regulation of the Prescription Drug Benefit)

Medicare Quality Measures

Policy 1403

10/07/2014 Introduced

10/28/2022 Revised

AMCP recognizes the essential role of pharmacists, PBMs, and health plans in improving the quality of care provided to patients and supports a measure development process that allows for timely integration of evidence-based medicine and feedback from stakeholders. AMCP additionally emphasizes the need to align measures across Medicare benefit programs to promote consistency, economic efficiency, and quality across the health care system. Quality measure policies need to be evaluated to ensure fair competition across all Medicare plan sponsors. 

(See AMCP Future of Medicare Part D Statement – Medicare Part D Quality Measures)

Value Based Contracts

Policy 1801

04/23/2018 Introduced