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Highlights: Understanding the Role of Pharmacy Benefit Managers

Elevance Health Impact
February 28, 2023

Panelists included Paul Marchetti, president of CarelonRx; Jeff White, Pharm.D., with CarelonRx; and Jennifer Kowalski, vice president of the Public Policy Institute at Elevance Health. Sarah Svoboda, a health policy director at the Public Policy Institute, moderated the event.

Pharmacy benefit managers (PBMs) manage the prescription drug portion of the health benefit for more than 266 million people in the United States. This includes individuals who are enrolled in commercial, government-sponsored, and employer group health plans. What is a PBM? What do they do? How do they help people?  Elevance Health convened a discussion  on these questions, and these are some of the highlights:

How PBMs help reduce prescription drug costs  

Paul Marchetti: “PBMs are the only entities within the broader drug supply chain that are incentivized to lower costs and advocate for members in the fight to keep prescription drugs accessible and affordable. If you look at drug [price] trends versus most consumer goods over the last 10 years, they’re lower, which means that PBMs are driving down the cost of drug prices even in the face of many new drugs coming to market.”

Jeff White: “There are about 20 drugs that are FDA approved each year on average. And we've seen recently many high-profile therapeutics approved. These therapies can be life changing. Some of these therapies can provide very little or limited clinical benefit at all. But the good news is we have our team [of pharmacists] behind the scenes that really understands the evidence of these drugs. We understand how well the drugs work. How well they will improve health. We also will see gene therapies that will be approved in the next couple of years. They are going to be very expensive, and our role is to help ensure clinically appropriate evidence-based use of these drugs and therapies to make sure the right patients are getting access to them.”

Pharmacy networks can help improve access

Jennifer Kowalski: “Pharmacy networks are groups of pharmacies that a health plan has contracted with, usually through a PBM, to provide convenient access to medications and care at an affordable price. The pharmacy networks help to provide broad access. They include large retail chains, small independent pharmacies, and mid-sized regional chains. Just as consumers save on out-of-pocket costs if they see a physician that’s in their health plan network, consumers also save on their out-of-pocket costs for medication if they get their prescription drug filled at a pharmacy that’s in their health plan network.”

How PBMs contribute to a holistic approach to care

Paul Marchetti: “When we started CarelonRx back in 2019, we built it not to be a traditional PBM, but one that focuses on delivering affordability, better outcomes and experience. What's different about CarelonRx is our focus on whole health [and health equity]. For example, a member who is taking specialty medications may also suffer from depression or be diabetic, which means that they need to be treated holistically. We organize our data and analytics along with our clinical programs to ensure that member gets their medication, but to also provide them with services from our behavioral health company and connectivity to providers. This allows us to close gaps in care and drive [medication] adherence.”

Jeff White: “PBMs can contribute to health equity by sharing access to [evidence-based] therapies to improve health… across all patient types, across all diseases, and doing that consistently to reach the broadest audience we can in order to improve health equity.”

When asked, “what’s one thing you want people to know about PBMs,” panelists said:

Paul Marchetti: “Pharmacy benefit managers are essential in the delivery of the healthcare benefit. We work to remove barriers, personalize experiences, contribute to health equity and improve health outcomes, no matter where people are in their healthcare journey.”

Jeff White: “From a pharmacist’s perspective, I value the work being done by PBMs to ensure patients have access to convenient, cost-effective and evidence-based medications that ultimately contribute to their overall health and wellness.”

Jennifer Kowalski: “In addition to processing prescription drug claims, PBMs add value by improving health outcomes using evidence-based clinical programs, by designing effective pharmacy networks, and reducing prescription drug spending and costs.”  

Follow Elevance Health on LinkedIn for more conversations like this. Comments have been edited for length and clarity.

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