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PBMs Offer Plan Services


PBM services add a different dimension to traditional healthcare, promoting increased industry innovation and broader adoption of value-based drug benefit designs.

Key Points

"PBMs are working effectively with their employer customers to create incentives for members to use the lowest cost medically appropriate drug for their illness or condition. Three-or more tier plan designs are used by 75.2% of employers," Felthouse says.

The most commonly used cost-sharing approach is a three-tier plan design with dollar copayments, she explains. According to a PBMI 2007 report, based on research conducted with 340 U.S. employers, about 45.3% of employers are using this plan configuration. About 16.8% are using the two-tier plan design with dollar copayments.

There are four key strategic phases to managing the pharmacy benefit: managing administrative costs (claims processing, online adjudication, eligibility verification, card programs, copay verification and benefit administration); managing drug unit costs (formulary, pharmacy network, mail-order, rebates, online formulary compliance, P&T support, NDC lockouts, internet pharmacy and management of inhouse pharmacies); managing drug utilization (drug utilization review, patient education and provider intervention); and managing diseases (disease management and outcomes studies).

"When choosing a PBM you need to clearly define your goals in offering pharmacy benefit coverage," Opdycke says. "Are you merely seeking to offer affordable access to drug products or are you aiming for a higher strategic goal to improve your beneficiaries' overall health status via appropriate use of drugs? Once you define your goals, then you should select a PBM with services and capabilities to match your needs."


Pharmacy benefit managers also are developing new medication therapy management (MTM) programs for commercially insured populations as a result of programs developed for the Medicare Part D beneficiaries, according to Felthouse.

"While many MTM programs are delivered through existing claims adjudication systems and drug utilization review functionality, there are several MTM offerings that include face-to-face pharmacist consults and polypharmacy case management," Felthouse says. "Effective MTM helps to ensure patients are getting optimal drug therapy."

Finally, a growing number of employers are paying community pharmacists to help employees learn to better manage diabetes, hypertension and other chronic conditions. "The return on investment is excellent," Felthouse says. "Pharmacist-coordinated health management programs are measurably improving employee health and lowering healthcare costs for employers."

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