New Material Flashcards
(38 cards)
Medicare
Health insurance for > 65 years old or certain disabilities
Who is Medicare administered by?
Centers for Medicare and Medicaid Services (CMS)
What are the four components of Medicare?
- Hospitalization
- Physician services
- Alternative to B (Medicare Advantage)
- Rx drug coverage
What certain drugs are excluded from coverage?
OTC, weight loss, fertility, cosmetics, ED
What do Medicare plans have to do when there are drug changes?
Notify CMS, providers, and patients
What must the pharmacy provide to the patient when a prescription cannot be covered at the point of sale?
Printed notice
Medication Therapy Management (MTM)
Ensures drugs are being used appropriately, optimizes therapeutic outcomes, and reduces adverse effects
Medicare Part D
May use formularies that incorporate tiers with variable copays, DURs, prior authorizations, quantity limits, and other restrictions
Plans may not require more than __ chronic diseases for a beneficiary to qualify for MTM services.
3
Plans must target ___ out of ___ core chronic conditions.
5, 9
Medicaid
Provides healthcare costs for certain
categories of indigent patients and is
administered by the state, jointly funded by the federal government and the state, with each state program subject to federal approval and federal regulation
Medicaid prescriptions
Must be written on
tamper-resistant prescription pads
False Claims Act
Prohibits knowingly presenting or causing to be presented
a false or fraudulent claim for payment or approval; it prohibits
knowingly making, using, or causing to be made or use a false
record or statement material to a false or fraudulent claim
Anti-Kickback Statute
Prohibits anyone from knowingly and willfully soliciting, receiving, offering, or paying any remuneration (including any
kickback, bribe, or rebate) in exchange for inducing referrals or for furnishing any goods or services paid for by Medicare or Medicaid
Stark Law
Prohibits certain healthcare providers from referring Medicare or Medicaid patients to certain entities in which the
healthcare provider (or an immediate family member) has a financial relationship.
Proof of a Stark violation
Does not require intent or that the
defendant acted willfully or knowingly
340B law
Requires that drug manufacturers
provide outpatient drugs at special reduced prices to
designated covered entities serving underserved and
uninsured populations
Federal law makes what illegal for the covered entity or
pharmacy to dispense or sell?
A 340B drug other than
to an eligible 340B beneficiary
The Patient Safety and Quality Improvement Act (PSQIA)
Creates a voluntary program through which healthcare providers can share information related to patient safety events with PSOs, and this information
is privileged and confidential
When did self-regulation of the pharmacy profession begin?
In the late 19th century
Self-governance continues at the what level?
State level, which limits the
federal authority over the practice of pharmacy.
In the United States, pharmacy is regulated through _________.
Licensure
What does licensure help?
Increase the quality of healthcare, reduce the cost of healthcare, and inhibit the criminal abuse of drugs
What do state laws that regulate the practice of pharmacy create?
State boards of pharmacy
