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In this episode of TechPrep: Rapid PTCB Review, we review utilization management with a focused, exam-relevant approach tailored to pharmacy technician practice and the PTCB exam. This episode explores how insurance plans and pharmacy benefit managers (PBMs) influence medication coverage, prescription claims, and access to treatment through formularies, prior authorizations, and other utilization management strategies.
Pharmacy technicians frequently encounter utilization management at the pharmacy counter, from refill-too-soon rejections and step therapy requirements to quantity limits and formulary restrictions. This episode breaks down the differences between prospective, concurrent, and retrospective drug utilization review, examines how PBMs and formulary decisions affect prescription coverage, and explains when patients may need additional documentation or alternative billing options. You'll also review medication substitution protocols, Medicare Part D protected drug classes, and the distinction between cost-management strategies and edits designed to protect patient safety.
What You'll Learn
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The role of PBMs, formulary management, and rebates in prescription drug coverage
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Differences between open, tiered, and closed formularies, including Medicare Part D protected classes
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Common utilization edits, including prior authorizations, step therapy, refill-too-soon rejections, age restrictions, and quantity limits
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How medical and pharmacy benefits differ, along with common drug class exclusions
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Differences between generic substitution, therapeutic interchange, and IV-to-oral medication conversion
Key Takeaways
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Formulary management determines which medications are preferred or covered, while utilization management establishes the requirements for accessing them.
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Understanding claim rejection reasons helps pharmacy technicians identify appropriate next steps and communicate more effectively with patients.
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Some restrictions focus on cost and coverage, while others—such as morphine equivalent dose edits—are designed to address medication safety.
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Knowing which substitution protocols are permitted in outpatient versus institutional settings is essential for pharmacy practice.
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