Managed Care
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More PBMs used for dispensing, utilization review

MANAGED CARE March 2011. © MediMedia USA
The Formulary Files

More PBMs used for dispensing, utilization review

MANAGED CARE March 2011. ©MediMedia USA

PPOs are increasingly looking to managed pharmacy programs to help manage drug utilization costs of members with chronic conditions who are taking numerous medications. In general, the larger the PPO (number of members), the more likely it is to use a managed pharmacy program. The Sanofi-Aventis Managed Care Digest Series — HMO-PPO Digest 2010–2011 suggests that in 2009, more than 80 percent of PPOs with 500,000 to 999,999 members had a managed pharmacy program, compared with about a quarter of plans that had fewer than 20,000 members.

By far, the most prevalent managed pharmacy programs involve pharmacy benefit managers. PBMs are playing a greater role as they are involved in administration, dispensing, utilization review, and claims and mail-service processing, according to the report.

With their specialized services in tracking electronic prescribing and medical records, PBMs should be experiencing heightened demand — especially with recent health reform emphasizing the importance of health information technology. For example, PPOs are using PBMs to dispense medications, with 82 percent using PBMs for this service in 2009, up from 78 percent in 2008.

Utilization review had a slight downturn in 2009, says the report, after having a sharp rise from 63 percent in 2006 to 76 percent in 2008. In 2009, almost three-quarters of PPOs surveyed said they used PBMs to provide drug utilization reviews. But the report says PPO reliance on PBMs for drug utilization review is likely to increase, “especially as pay-for-performance and outcomes measures become more prominent in the post-reform era.”

Various services provided by PBMs to PPOs

Source: Sanofi-Aventis Managed Care Digest Series — HMO–PPO Digest 2010–2011

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