Pharmacy Benefit Management

Pharmacy benefit management (PBM) companies administer drug benefit programs for employers and health insurance carriers. PBMs contract with managed-care organizations, self-insured companies, insurance companies, unions and government programs to manage prescription drug benefits, drug utilization review, outcomes research and disease management. Some 95% of all patients with drug coverage receive benefits through PBMs. In 2009, 3.8 billion prescriptions were administered in the US—about 70% of those through PBMs.

UL maintains an alliance with PBMI to develop unique online training programs for PBMs, managed-care and other insurance programs.  Because of their enormous buying power, PBMs have significant compliance and communications responsibilities to their customers. Further, PBMs have expanded their services to include more personalized programs, such as disease and drug therapy management.

The Office of Inspector General (OIG) 2010 Work Plan focuses directly on PBM oversight. Two new parts in the plan will require new compliance procedures, training and communications. The first is the required review of CMS and Medicare Part D plan sponsors’ oversight of PBMs. The second is the evaluation of whether Part D sponsors’ contracts with PBMs comply with regulations, with specific focus on administrative and legal provisions that include reporting responsibilities, performance monitoring and compliance.

UL’s PBM training library, along with its Medicare Advantage, Part D, HIPAA and regulatory libraries, are available for single or small group purchase through the PBMI Web site. Larger groups should contact UL EduNeering directly.