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Insurance & PBMs

Submitting and reconciling health insurance and pharmacy benefit claims take up a lot of time. Learn how to communicate most effectively and efficiently with insurers, patients, doctors and nurses to get coverage issues resolved. Third-party payers, Medicaid and Medicare all differ, so learning the ins and outs of each systems is essential.

Health Reform FAQS - Answers to Your Questions About the Affordable Care Act
Get the most basic information on what changes to health care coverage patients can expect, like whether college-age children can stay on their parents' plans and whether Medicare Part D drug plans will remain in effect.

Health Reform Timeline - Year-by-Year Implementation 2010 through 2014
Read brief, plain-language descriptions of what and when provisions of the Patient Protection and Affordable Care Act -- Obamacare -- will take effect.

What Obamacare Means for Community Pharmacists
Billing Medicaid, selling DMEPOS and providing medication therapy management services in community pharmacies will change as provisions of the Patient Protection and Affordable Care Act take effect.

What Obamacare Means for Health-System Pharmacists
The Patient Protection and Affordable Care Act creates opportunities for health-system pharmacists to use their medication therapy management skills to reduce hospital and long-term care admissions, prevent medication errors, and keep readmissions to a minimum.

What the Obamacare Health Insurance Rules Mean for Pharmacy
Each insurance plan must cover at least one medication in each of the 50 drug categories defined by the U.S. Pharmacopeia.

A Quick Overview of Medicare and Medicaid
Review the major differences between the government-funded health plans administered by the Centers for Medicare & Medicaid Services at the federal level and state health departments at the local level, including who is eligible for which benefit.

PBM, Medicare and Medicaid Reimbursement Terms, Part 1: AMP to FUL
Payments from health insurance companies, pharmacy benefits managers, Medicare and Medicaid to pharmacies vary according to how average manufacturer price, average sale price, average wholesale price, federal upper limit and maximum allowable cost are calculated.

PBM, Medicare and Medicaid Reimbursement Terms, Part 2: MAC to WAMP
Insurance payments to pharmacies can vary according to how average manufacturer price, average sale price, federal upper limit, maximum allowable cost and widely available market price are calculated.

Medicare and Drug Compounding
Pharmacists and pharmacy technicians must understand the rules for compounded drug coverage under Medicare and Medicaid to ensure all patients get the medications they need.

Tips for Helping Patients Choose Medicare Part D Prescription Drug Plans
Pharmacists need to be prepared to help seniors and adults with permanent disabilities find and sort through PDP information.

How To Deal With Insurance Companies
Following these 12 tips for quickly getting coverage questions answered can make your day in the pharmacy much smoother.

Top 5 Pharmacy Benefits Managers
This list includes basic facts about the largest PBMs as measured by covered lives and prescription volumes.

The Big Five: Health Insurance Companies
Get the basics on WellPoint, Cigna, Aetna, Humana and United Healthcare.

DMEPOS 101 for Pharmacists, Pharmacy Technicians and Pharmacy Clerks
Billing private insurance companies, Medicare and Medicaid for durable medical equipment, prosthetics, orthotics and supplies presents challenges for pharmacists, pharmacy technicians and clerks in chain and independent community pharmacies.

Frequently Asked Medicare Questions
Get answers to questions like what health care procedures and drugs Part A, Part B and Part D cover, as well as how federal health care reform affects Medicare beneficiaries.

What Are the Differences Between HMOs and PPOs?
This info from the About Health Insurance site helps patients decide whether a health maintenance organization or a preferred provider organization will best serve their health insurance needs.

Insurance Codes -- Learn About Insurance Codes to Avoid Billing Errors
CPTs? ICDs? ECBs? Visit this page to find out what these all-important acronyms mean and how to properly fill out pharmacy benefit insurance claim forms.

How to Do Pharmacy Billing
This how-to article starts with the most basic step of registering for a federally recognized pharmacy billing number and proceeds through the final step of interpreting contracts with third-party payers.

ACOs -- Accountable Care Organizations
Accountable Care Organizations were created under the Patient Protection and Affordable Care Act to make it easier for pharmacists to collaborate and coordinated with doctors and other health care when treating Medicare beneficiaries.

Medical Homes -- aka, Health Homes
Also known as health homes, medical homes allow doctors, pharmacists and counselors to provide collaborative health care to chronically ill Medicaid beneficiaries.

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