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  4. > IMS Pharmaceutical Pricing & Reimbursement Concise Guide: USA

The Pharmaceutical Pricing & Reimbursement Concise Guides are established as the definitive reference and training text for P&R professionals around the world, drawing on the long-standing expertise of the IMS pricing and reimbursement specialists to provide industry players and decision makers with a thorough understanding of the rules and regulations governing P&R in international markets. This report covers key developments in P&R, market access, cost containment, trade margins and healthcare issues.

Table Of Contents

IMS Pharmaceutical Pricing and Reimbursement Concise Guide: USA
USA 1
HEALTHCARE SYSTEM 1
Facts and Figures 1
Market Indicators 2
Provision and Funding 4
Patient Protection and Affordable Care Act 5
Medicare 8
Medicaid 9
Uninsured 11
PRICING 11
Prescription Drugs 11
Price Controversies 11
Pricing Benchmarks 12
Private Payers 13
Medicare 15
Medicaid 17
Generic Drugs 18
Private Payers 18
Medicare 19
Medicaid 19
Hospital Drugs 19
Procurement 19
340B Drug Programme 19
OTC Drugs 20
REIMBURSEMENT 20
Admission to Reimbursement 20
Private Payers 21
Medicare 23
Medicaid 26
Other Federal Programmes 26
Reimbursement Categories 27
Private Payers 27
Medicare 28
Medicaid 29
Reimbursement Prices 29
Private Payers 29
Medicare 31
Medicaid 31
Hospital Reimbursement 33
Formularies 33
Private Payers 33
Medicare 34
USA, Pharmaceutical Pricing and Reimbursement Concise Guide
v
Medicaid 35
340B Programme 36
Changes in Reimbursement Status 36
Private Payers 36
Medicare 37
Medicaid 38
Changes in Reimbursement Prices 38
Private Payers 38
Medicare 39
Medicaid 40
PHARMACOECONOMICS 40
Pharmacoeconomic Requirements 40
Private Payers 40
Medicare 42
Medicaid 43
Patient-Centered Outcomes Research Institute 43
PRICE BUILD UP 43
Wholesalers 43
Margins 43
Background 43
Retail Pharmacies 44
Margins 44
Dispensing Fees 44
Background 46
Dispensing Doctors 46
Sales Tax 46
Prescription Drugs 46
OTC Drugs 47
COST CONTAINMENT 47
Industry Paybacks 47
Annual Fees 47
User Fees 48
Promotional Costs 48
Advertising 48
Payments to Physicians 49
Patient Co-payments 49
Private Payers 49
Medicare 52
Medicaid 56
Pharmaceutical Assistance Programmes 57
Uninsured 57
Prescribing Controls 57
Formularies 58
Utilisation Controls 58
Off-label Prescribing 59
USA, Pharmaceutical Pricing and Reimbursement Concise Guide
vi
Monitoring 59
Other Initiatives 60
Generics 60
Measures to Boost Generic Uptake 60
Barriers to Generic Uptake 61
Biosimilars 63
Rx-to-OTC Switches 65
Switching Process 65
OTC Sales 65
Parallel Trade 66
Re-importation 66
FUTURE DEVELOPMENTS 66
Outlook 66
Healthcare Reform 66
Drug Pricing Proposals 67
Medicare Part D Price Negotiations 68
Medicare Part B Reimbursement Reform 69
Medicaid Rebate 69
State-level Action on Drug Pricing 69
MAC Transparency 70
NAMES and ADDRESSES 70

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