PBM pharmacists don’t fit the stereotypical image of a pharmacist behind the counter in a white coat dispensing medications. The role of managed care pharmacists (pharmacists in managed care organizations including PBMs and health plans) goes far beyond drug distribution. So, what do they do on a day-to-day basis? Collectively, they provide prescription benefits to over 200 million Americans, and ultimately, it’s their job to ensure an employer’s plan offers appropriate, cost-effective medications to improve a Member’s overall health.
In the spirit of American Pharmacists Month, here’s a look at what your PBM pharmacists tackle every day for you and your Members.
Pharmacists use a number of tactics to ensure the safety of your Members and the medications they are prescribed:
- Prior Authorizations: This pre-approval process helps guarantee plan compliance, ensures the drug, dose and length of therapy are appropriate for a Member’s diagnosis and ensures the Member is taking the most effective medication at the best possible price.
- Drug Utilization Reviews: DURs aim to recognize potential problems such as therapeutic duplications, drug interactions and over or under utilization.
- Fraud, Waste & Abuse: These programs are intended to prevent prescription abuse in key medication classes and eliminate waste in drugs where there are high non-compliance and discontinuation rates. Some of MedTrak’s specific FW&A programs include Opioid Management, RightMix Compound program and Starter Dose program.
Clinical Programs & Plan Design
Managed care pharmacists continually enhance and develop new programs and create plan designs aimed at curbing pharmacy costs for Plan Sponsors and improving Member care. As new drugs come to market, they are evaluated to determine the effectiveness and quality of the medication and considered for possible inclusion on a formulary. Pharmacists work hand-in-hand with Plan Sponsors to decide which type of formulary they should use (open, closed or exclusion formulary) and other plan design elements such as how expansive the pharmacy network should be or their approach for covering certain high-costing medications, such as specialty drugs.
One of the most important aspects of a managed care pharmacist’s job is educating their Members. Informed Members are more likely to comply with their drug regimen and choose lower-cost alternatives. Managed care pharmacists provide communication to Members on drug safety alerts, their prescription history, available medications that will effectively treat their condition and save them money and provide on-going support by being available to answer any questions that arise.
At MedTrak, we have a full staff of highly trained pharmacists in our Clinical Care Center who provide these types of services to our Clients and Members. They work day-in and day-out to ensure we are offering top-notch clinical services and programs, and we are grateful for their dedication to our Plan Sponsors!
Source: ‘Roles of Pharmacists in Managed Health Care Organizations’ by the Academy of Managed Care Pharmacy.
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