2 What are PBMs?Rising health care costs have forced employers and health plans to develop methods to manage costsPBMs-are private companies hired by employers and health plans to help administer drug benefits
3 PBM’s function Purchase and dispense medications Pay claims Financial intermediary between pharmacies and plan sponsorManage prescribing choicesMaintain pharmacy networks
4 PBM’s added services Real-time medication check PBMs conduct electronic clinical reviews before medications are dispensedPrescription is checked for:●Drug-drug interaction●Drug-age interaction●Appropriate dosage●Excessive utilization■ Pharmacists at point-of-sale receives a real time alert
5 Why is there a rise in PBMs 3 main reasons:1)Number of RXs per person increases2)Newer, higher costs RXs are replacing older, less costly medications3)The prices of RX drugs are increasing
6 Most Dominant PBMsCaremark, Inc. (merged with Advance PCS)-90 million covered livesMedco Health Solutions, Inc.-60 million covered livesExpress Scripts, Inc-40 million covered lives
7 Focus of PBMs ■ Negotiate the customer’s ultimate cost a) reimbursement to retail pharmacyb)payment to manufacturer of the drug■ Establish network of participating pharmacies■ Negotiate rebates with drug manufacturers
8 Who is in charge? Ultimately, the health plan is in charge PBMs are not wholesalers and do not generally purchase and sell RX drugsBut, many PBMs own a mail order pharmacy
9 Problems with PBMsPBMs are paid for services which are not considered rebatesUse of call centers to actively encourage doctors to switch individual patients to preferred drugRefusal to disclose information on the prices they pay for drugs, as well as the rebates amounts
10 Problems with PBMs continued Collection and sale of PBM data on patientsPharmacy spread-the difference between the price charged health plans and the price paid pharmaciesMail-order pharmacy
11 Pharmacist’s Role in PBMs 3 Clinical InterventionsA)Therapeutic InterchangeB)Medication AdherenceC)Therapy Management
12 Pharmacists Role Goals Increase quality of care to membersPromote appropriate drug therapyEnhances medication complianceImproves preferred drug complianceIncreases utilization of cost-effective pharmaceuticals
13 Things to ask for when selecting a PBM Does the PBM uses the same AWP in calculating price to clients and payments to pharmacies?Are there any other payments a PBM gets from drug manufacturers besides rebates?How often a PBM changes their formulary?
14 More questions to ask How are co-payments set? Ask for detailed disclosure and explanation of a PBMs fee scheduleWhat is PBM’s policy on selling pharmacy data?
15 Duties to be performed by the client in the contract Must provide a PBM with :● Eligible member list● Benefit plan information●Notification requirements● Provision of Eligibility Info● Business development
16 In SummaryPBMs manage the majority of prescriptions that flow through health care systemPBM industry has evolved from small claims processing firms to more concentrated industry with comprehensive service offeringsKeep in mind that PBMs are a for-profit businessNot always looking out for the best interest of the client or patient