The Effect of Pharmacy Benefit Manager Clinical Programs and Services on Access to Prescription Drug Benefit Coverage
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Drirg Informarion Journal, Vol. 32. pp. 373-377. 1998 Printed in the USA. All righrs reserved.
THE EFFECT OF PHARMACY BENEFIT MANAGER CLINICAL PROGRAMS AND SERVICES ON ACCESS TO PRESCRIPTION DRUG BENEFIT COVERAGE J. RUSSELLTEAGARDEN Merck-Medco Managed Care, L.L.C., Montvale, New Jersey
This paper provides an overview of the effects of a pharmacy benefit manager S programs and services on access to prescription drug coverage. Coverage is increasingly used by prescription drug benefit plans as u means to reduce the potential for exposure to unnecessary costs of providing the benefit. Certain fundamentals must be adhered to so as to avoid creating unintended and inappropriate barriers to access and an appeals process must be in place. Merck-Medco 's development and implementation of its clinical programs and services that involve prescription drug coverage decisions is highlighted. Key Words: Pharmacy benefit manager; Prescription drug coverage
THIS PAPER ADDRESSES the effect of pharmacy benefit managers' (PBM's) clinical programs and services on access to prescription drug coverage, including its relevance to the issue of off-label uses and highcost drugs. Pharmacy benefit management can represent a commercial enterprise, or a component of a commercial enterprise, or it can be viewed as referring to a group of related activities. In either form, its purpose is aimed at reconciling the infinite desires of individuals for unfettered access to pharmaceuticals with the finite resources of prescription drug payers. Therefore, PBM activity is found in many environments, and includes managed care organizations, hospitals, insur-
Presented at the DIA 33rd Annual Meeting "Optimizing Pharmaceutical Development: The Global Experience," June 22-26. 1997, Montreal, Canada. Reprint address: J. Russell Teagarden, MerckMedco Managed Care, L.L.C.. 100 Summit Ave., Montvale, NJ 07645.
ance carriers (eg, Blue Cross/Blue Shield), integrated health care systems, and physician practice groups. PBMs provide many clinical programs and services, but only a few are specific to determining whether a drug is covered on a case-by-case basis for individual patients beyond that which is done with the conventional point-of-service electronic or paper claim transactions. This paper focuses on those programs and services specific to Merck-Medco, which may or may not be generalizable to any other organization providing pharmacy benefit management or like services.
GENERAL PURPOSE OF PROGRAMS RELATED TO BENEFIT COVERAGE The purpose of clinical programs and services that determine prescription drug coverage is primarily to address the scope of the benefit. The scope of prescription drug bene-
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J. Russell Teagarden
fits can vary for different reasons, and the reasons can be based on financial factors, philosophical positions, or competitive issues. Nonetheless, plans have certain reasons for putting together a benefit plan the way they do, but there
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