Understanding the Role of Pharmacy Benefit Managers in Healthcare
Pharmacy benefit managers (PBMs) positively contribute to overall member health and fulfill a critical role in the healthcare system. PBMs increase access to safe and effective medications for individuals while simultaneously reducing drug spending and costs.
PBMs manage the prescription drug portion of the health benefit for more than 266 million Americans. This includes individuals who are enrolled in commercial, government-sponsored, and employer group health plans. PBMs add value in three primary ways: improving health outcomes using evidence-based clinical programs, designing effective pharmacy networks, and reducing prescription drug spending and costs.
Successful administration of the prescription drug benefit requires weaving together these strategies in a way that is customized for each population; this can include formulary management, digital tools, and value-based payment models. This paper explores how PBMs enhance member outcomes and deliver economic value to the healthcare system.
Related Public Policy Research
PBMs Help Improve Medicaid Outcomes with Pharmacy-Centered Care Programs
Individuals enrolled in Medicaid frequently experience elevated rates of chronic conditions, challenges with medication adherence, and fragmented care coordination. By partnering with local pharmacies, pharmacy benefit managers can help improve medication adherence, enhance chronic condition management, and support the delivery of preventive care—efforts that may also contribute to reduced long-term healthcare costs.
Pharmacy Benefit Manager Safety Measures for Opioids for Dental Pain
Anyone who takes prescription opioids to manage acute or chronic pain can develop opioid use disorder (OUD), a problematic pattern of opioid use that causes significant impairment or distress. Elevance Health’s CarelonRx pharmacy benefit manager (PBM) implemented a policy in 2020 that has successfully mitigated unnecessary and inappropriate prescribing of opioids for the treatment of dental pain.
Medicaid Prescription Drug Management: Quality Scores Compared Across Different Approaches
Data show that states that employ managed care organizations (MCOs) to manage the Medicaid prescription drug benefit collectively exhibit higher scores on pharmacy-related clinical quality measures than states that rely on the fee-for-service (FFS) setting to administer the benefit.