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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 | |