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Contributors | |
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Foreword | |
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Preface | |
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Acknowledgments | |
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Fundamentals of Managed Care Pharmacy Benefit Management | |
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The U.S. Health Care System and the Development of Managed Care | |
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Introduction to U.S. Health Insurance Industry | |
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Evolution of the Health Insurance Industry | |
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Economic Basis for the Development of Managed Care | |
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Early Development of Managed Care | |
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HMO Act of 1973 | |
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Federal and State Growth in Managed Care: Medicare and Medicaid | |
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MCOs: More than HMOs | |
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Physician Reimbursement Mechanisms | |
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Gatekeeper Physicians | |
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Risk Sharing of Pharmacy Cost | |
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Carve-Out and Ancillary Health Care Benefits | |
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Quest for Quality | |
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Impact of Managed Care on Physicians and Pharmacists | |
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Member Involvement in Managed Care | |
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Conclusion | |
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Pharmacy Benefit Management Principles and Practices | |
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Basis for Pharmacy Benefit Management | |
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Principles of Pharmacy Benefit Management | |
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Growth of PBMs | |
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Pharmacy Benefit Management Program Components | |
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Advanced Pharmacy Benefit Management Components | |
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Measuring Pharmacy Benefit Management Program Performance | |
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Conclusion | |
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Pharmacy Benefit Design, Contracting, and Marketing | |
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Business Basis for Pharmacy Benefit Management | |
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Corporate and Government Impetus for Pharmacy Benefit Management | |
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Legal Basis of Pharmacy Benefit Management | |
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Benefit Design, State Requirements | |
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Principles of Marketing Pharmacy Benefits | |
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Payer and Patient Expectations and Decision Points | |
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Role of Members in Pharmacy Benefit Provider Selection | |
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Pharmacy Performance Measurements Important in Marketing | |
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Marketing Campaign Advertisement Examples | |
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Marketing Process | |
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Pharmacy Benefit Contracting Components | |
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Pharmacy Benefit Management Contracting Trends | |
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Risk Contracting | |
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Overview of Impact of Medicare and Medicaid | |
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Risk-Contracting Elements and Executions | |
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Payer Expectations | |
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Performance Measurement | |
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Future Trends in Pharmacy Benefit Design and Contracting | |
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Conclusion | |
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Appendix 3-A | |
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Appendix 3-B | |
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Pharmacy Distribution Systems and Network Management | |
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Pharmacy Program Distribution Options | |
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Community Pharmacy Provider Networks | |
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Pharmacy Provider Network Development | |
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Pharmacy Provider Network Contracting | |
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Participating Pharmacy Provider Agreement | |
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Participating Pharmacy Provider Manual | |
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Participating Pharmacy Network Management Issues | |
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Measuring Performance | |
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Audits | |
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Reports | |
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Member Satisfaction | |
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In-House Pharmacies | |
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Mail Service Pharmacy | |
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Developing an Integrated Distribution System | |
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Pharmacist's Role | |
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Impact of Managed Care on the Profession of Pharmacy | |
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Conclusion | |
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Appendix 4-A | |
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Pharmacy Data and Information Systems | |
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Scope of Pharmacy Information Management | |
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Pharmacy Information Management Systems | |
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PMSs and Electronic Data Interchange | |
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Role of Switching Companies | |
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Internet Technology | |
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Adjudication Systems | |
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Other MCO Information Systems | |
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Conclusion | |
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Drug Formulary Management | |
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History and Purpose of Drug Formularies | |
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Definitions | |
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Why Formularies? | |
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Decision-Making Process | |
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Formulary Exception Process | |
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Formularies' Relationship to Other Pharmaceutical Care Practices | |
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Future Directions | |
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Conclusion | |
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Drug Utilization Review Strategies | |
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History and Current Role of DUE/DUR | |
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Types of DURs | |
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Steps in Conducting DURs | |
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Application of DUR in Pharmacy Benefit Management | |
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Prior Authorization | |
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Prospective DUR | |
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Physician Education Programs | |
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Performance Measurement of DUR Programs | |
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Evolution of DUR | |
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Conclusion | |
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Member Satisfaction Strategies | |
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Importance of Member Satisfaction | |
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National Committee for Quality Assurance and Health Plan Employer Data and Information Set | |
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Satisfaction Measurement among Employer Groups | |
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Member Satisfaction with Pharmacy Benefits | |
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Conclusion | |
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Pharmacy Program Performance Measurement | |
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Role of Pharmacy Benefits in Overall Health Plan Performance | |
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Pharmacy Performance Metrics | |
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Measuring Performance of Various Components | |
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Interpreting Results of Pharmacy Measurement | |
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Interpreting Cost Metrics | |
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Communication of Pharmacy Program Results | |
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Application of Results for Program Improvement | |
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Advanced Outcomes Management Metrics | |
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Linking Pharmacy Programs to Overall Medical and Economic Outcomes | |
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Conclusion | |
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Pharmacy Benefit Management Companies | |
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Genesis of PBMs | |
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Growth and Evolution of PBMs | |
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Outsourcing Pharmacy Benefit Management to a PBM | |
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Financial Arrangement between PBMs and Their Customers | |
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Projecting Cost Savings Using PBM Services | |
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Reintegrating the Value of PBM Services | |
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Contracting for PBM Services | |
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Conclusion | |
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Advanced Pharmacy Benefit Management Strategies | |
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Medicaid Pharmacy Benefit Management | |
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Legislative History | |
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Administration of Medicaid Benefits | |
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Funding Medicaid Benefits | |
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Medicaid Eligibility | |
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Medicaid Services | |
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Medicaid Benefit Design | |
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Managed Care Waivers | |
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Medicaid Managed Care Contracts | |
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Performance Measures and Member Satisfaction | |
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Medicaid Pharmacy Benefit Design | |
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OTC Product Coverage | |
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Medicaid Prescription Copayments | |
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Dispensing Fees | |
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Pharmaceutical Manufacturer Rebates | |
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Challenges and Opportunities in Medicaid Pharmacy Benefit Management | |
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Medicaid Demographic Challenges | |
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Developmental and Cultural Issues | |
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Traditional Fee-For-Service Medicaid Benefit Management Challenges | |
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Managed Care Challenges in Providing Medicaid Benefits | |
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Pharmacy Benefit Management Opportunities | |
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Future Managed Care Medicaid Trends | |
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Conclusion | |
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Medicare Pharmacy Benefit Management | |
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The Social Security Act of 1965 and the Tax Equity and Fiscal Responsibility Act | |
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Benefits Covered under Medicare | |
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Types of Medicare Programs | |
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Why Medicare Enrollees Prefer HMOs to Traditional Medicare | |
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Prescription Use and the Medicare Patient | |
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Management of the Medicare Prescription Drug Benefit | |
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Location of Network Pharmacies | |
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Drug Formularies | |
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Mail Order | |
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Drug Utilization Review | |
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The Future of Medicare | |
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Conclusion | |
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Quality Improvement Initiatives in Managed Care | |
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Defining Quality Health Care | |
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Assigning Accountability | |
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Measuring Quality | |
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Current Quality Improvement Initiatives | |
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NCQA | |
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Joint Commission | |
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American Accreditation Healthcare Commission/The Utilization Review Accreditation Commission | |
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FACCT | |
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AHCPR | |
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HCFA | |
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Other Quality Improvement Initiatives | |
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Future of Quality Measurement in Managed Care | |
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Role of Pharmacists | |
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Conclusion | |
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Health Informatics Systems | |
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Evolution of Pharmacy Data Standardization | |
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EDI and Electronic Commerce | |
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Data and Information Needs of Managed Care | |
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Pharmacy and Medical Claims Integration | |
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Electronic Medical Record Data | |
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Building a Data Warehouse | |
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Patient Outcomes Assessment | |
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Electronic Prescribing | |
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Merging Retrospective and Transactional Data | |
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Pharmacy and Health Telematics | |
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On-Line Patient Marketing | |
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Conclusion | |
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Provider and Vendor Risk Contracts | |
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Pharmacy Risk Contracting | |
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Physician Risk Contracts | |
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Reimbursement Agreements | |
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Choosing a Reimbursement Methodology | |
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Quality Issues | |
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Forecast | |
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Conclusion | |
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Disease Management Programs | |
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Definition and Goals | |
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Rationale | |
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Medical Conditions Appropriate for Disease Management | |
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Disease Management Process | |
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Growth of Disease Management | |
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Role of Pharmacy Benefit Management Companies | |
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Pharmaceutical Manufacturer Role in Disease Management | |
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Role of Physicians in Disease Management | |
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Role of Pharmacists in Disease Management | |
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Role and Source of Disease Management Guidelines | |
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Role of Drug Formularies in Disease Management | |
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Modifying Participant Behavior | |
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Barriers to Successful Programs | |
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Specialty Carve-Out and Carve-In Disease Management Companies | |
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Measuring Program Performance | |
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Conclusion | |
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Pharmacoeconomic Research and Applications in Managed Care | |
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Basics of Pharmacoeconomic Research | |
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Application of Pharmacoeconomics in Pharmaceutical Companies | |
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Use of Pharmacoeconomic Data for Effectiveness Claims | |
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Role of Pharmacoeconomic Research in Product Management | |
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Pharmacoeconomic Information Strategies within Pharmaceutical Companies | |
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Packaging Pharmacoeconomic Data for Use by P and T Committees | |
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Role of Pharmacoeconomic Data in Evidence-Based Drug Formularies | |
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Research Opportunities for Managed Care Organizations and PBMs | |
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Role of Pharmacoeconomics in Decompartmentalizing Plan Management | |
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Sources of Data | |
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Opportunities for Pharmacists in Pharmacoeconomic Research and Applications | |
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Conclusion | |
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The Role of the Pharmaceutical Industry in Managed Health Care | |
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Influence of Managed Care on the Sales of Pharmaceuticals | |
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Relationship of Pharmaceutical Manufacturers to Managed Care | |
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Evolution of the Pharmaceutical Marketplace | |
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Managed Care Marketing Strategy Development | |
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Contractual Relationships between the Pharmaceutical and Managed Care Industries | |
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Pharmaceutical Company Support Services for Managed Care | |
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Future Relationship of Pharmaceutical Manufacturers with Managed Care | |
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Pharmacy Practice Issues in Managed Care | |
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The Impact of Managed Care on Pharmacy Practice | |
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Impact of Managed Care Programs on Pharmacy | |
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Reimbursement for Managed Care Prescriptions | |
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Administration of Managed Care Prescription Contracts | |
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Managed Care Strategies for Pharmacists | |
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Effect of Managed Care on Hospital Pharmacies | |
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Conclusion | |
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Pharmaceutical Care in Managed Care | |
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Current Trends | |
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Examples of Pharmaceutical Care in Managed Care | |
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Impact of Pharmaceutical Care in Managed Care: Cost and Quality | |
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Reimbursement for Pharmaceutical Care: Cognitive Services | |
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Conclusion | |
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Pharmacist Career Path Opportunities in Managed Care | |
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The Future of Pharmacy under Managed Care | |
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Preparing for a Career in Managed Health Care | |
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Novel Career Opportunities | |
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Maintaining Career Viability | |
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Questions Surrounding an Uncertain Future | |
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Professional Responsibilities toward Career | |
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Conclusion | |
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Ethical Aspects of Pharmacy Practice in Managed Care | |
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Examples of Ethical Issues and Concerns | |
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Ethical Values: Their Place in Pharmacy Practice | |
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Ethical Principles and Concepts in Pharmacy Practice | |
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Resources for Managing Ethical Concerns in Pharmacy Practice | |
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Conclusion | |
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Drug Policy and Regulation in Managed Care | |
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Food and Drug Administration Issues | |
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Direct-to-Consumer Advertising | |
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Patient "Bill of Rights" Initiatives | |
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Patient Privacy Issues | |
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Fraud and Abuse and Consumer Protection Legislation | |
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Therapeutic Interchange | |
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Narrow Therapeutic Index Drugs | |
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Employee Retirement Income Security Act | |
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Licensing | |
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Any Willing Provider and Freedom of Choice Legislation | |
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Mail Service Pharmacies | |
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Conclusion | |
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International Opportunities for Pharmacists in Managed Care | |
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Managed Care Techniques | |
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Austria | |
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Denmark | |
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Finland | |
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France | |
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Germany | |
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Italy | |
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The Netherlands | |
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Norway | |
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Sweden | |
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Switzerland | |
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United Kingdom | |
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Career Opportunities Abroad | |
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Conclusion | |
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Future of Pharmacy Benefit Management | |
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Forces of Change | |
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Reaction and Interaction of Change Forces | |
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Impact of Forces of Change | |
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Pharmacy Practice in the Year 2000 and Beyond | |
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Conclusion | |
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Glossary | |
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About the Contributors | |
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Index | |