MCCCD Program Description

Specialty Pharmaceuticals II

Course: CSR170

First Term: 2010 Spring

Lecture 2 Credit(s) 2 Period(s) 2 Load
Subject Type: Occupational
Load Formula: S

Description: Specialty pharmacy and pharmaceuticals management. Covers third party administration, prior authorizations, and systems for coding, billing, and payments. Also includes payer plans and benefits in addition to special group plans and services.

MCCCD Official Course Competencies
1. Explain the role of the Pharmacy Benefits Manager. (I) 2. Explain the use of third party administrators. (II) 3. Differentiate between various coding, billing, and payment systems. (III) 4. Explain the billing and coding cycle for physician administered drugs. (III) 5. Describe Medicare payment systems. (IV) 6. Describe the transition to Average Sale Price (ASP) process. (IV) 7. Trace the prior authorization process. (V) 8. Differentiate between pre-certification and prior authorization. (V) 9. Define the terms ¿payer¿ and ¿reimbursement¿. (VI) 10. Explain the difference between commercial and public payers. (VI) 11. Differentiate between various types of plans. (VI) 12. Explain reasons for Veteran¿s Administration (VA) priority groups. (VII) 13. Describe eligibility requirements for VA priority groups. (VII) 14. Explain Indian Health Service (IHS) benefit design and services. (VII) 15. Explain the procedures for determining State Children¿s Health Insurance Plan (SCHIP) coverage. (VII) 16. Describe SCHIP funding. (VII)
MCCCD Official Course Competencies must be coordinated with the content outline so that each major point in the outline serves one or more competencies. MCCCD faculty retains authority in determining the pedagogical approach, methodology, content sequencing, and assessment metrics for student work. Please see individual course syllabi for additional information, including specific course requirements.

MCCCD Official Course Outline
I. Pharmacy Benefits Managers A. Role B. Operation C. Affects 1. Patients 2. Prices 3. Insurance Verification II. Third Party Administrators A. Definition B. Role III. Coding, Billing, and Payment A. Systems 1. International Classification of Diseases 9th Edition Clinical Modification (ICD-9) 2. Current Procedural Technology (CPT) 3. Healthcare Common Procedure Coding Systems (HCPCS) 4. National Drug Code (NDC) B. Forms C. Cycles 1. Coding 2. Billing D. Payments 1. Fee for Service 2. Systems IV. Buy and Bill A. Definition B. Impact C. Medicare Modernization Act D. Average Wholesale Price E. Wholesale Acquisition Cost F. Average Sale Price 1. Definition 2. Transition 3. Medicare Payment G. Competitive Acquisition Program 1. Definition 2. Process H. Private Payers V. Prior Authorization A. Definition B. Use C. Process 1. Electronic 2. Hard Copy 3. Mail Service D. Vs. Pre-Certification E. Drug Requirements F. Step Therapy G. Impact VI. Payers A. Terms B. Types 1. Commercial 2. Public C. Health Risk D. Plans 1. Health Maintenance Organization (HMO) 2. Preferred Provider Organization (PPO) 3. Point of Service (POS) E. Benefits 1. Pharmacy Carve Out 2. Employer-Purchase 3. Pharmacy Benefits Manager VII. Special Groups A. Veteran¿s Administration (VA) 1. Benefits 2. Eligibility 3. Out of Pocket Expenses 4. Thresholds 5. Compensable Disability 6. Priority Groups 7. Outpatient Co-Pay B. Indian Health Service (IHS) 1. Charter 2. Services 3. Benefit Design 4. Medicare Eligibility C. State Children¿s Health Insurance Plan (SCHIP) 1. Administration 2. Funding 3. Eligibility

MCCCD Governing Board Approval Date: 12/8/2009

All information published is subject to change without notice. Every effort has been made to ensure the accuracy of information presented, but based on the dynamic nature of the curricular process, course and program information is subject to change in order to reflect the most current information available.