PHARMACIST’S ROLE IN HEALTH INSURANCE BENEFIT DESIGN

To advocate that pharmacy practice leaders collaborate with internal and external partners who design, negotiate, and select their own organization's health plans and pharmacy benefit management contracts to preserve patient continuity of care and the integrity of the health-system pharmacy enterprise; further,

To provide education and resources for all partners on the health plan development process, analysis of pharmacy benefit design, contemporary formulary review processes, and application of medication safety principles on formulary decision-making.

Rationale

Pharmacy leadership should be directly involved in the selection of the health system’s pharmacy benefit manager (PBM) servicing their employees’ health plan, and the terms of that contract with that PBM. Employers typically look to balance value for the employee while attempting to control costs. As health systems evaluate and select plans, there may not always be due consideration given to the potential impacts on patient continuity of care and on that health system’s pharmacy enterprise and financial solvency in servicing employees’ prescriptions through the selected PBM. Aside from the safety and continuity of care implications to the patient if the health system’s pharmacy is excluded from the employees’ network, organizations may unknowingly undermine utilization of their outpatient cancer and infusion programs. Three PBMs control the majority of the PBM market, exerting heavy influence in costs, pharmacy participation, formulary, and prior authorization criteria. By including pharmacy leadership to help make a well-informed decision about selecting a servicing PBM for a health system, and the contract terms associated with that PBM (i.e., clinical and financial aspects), some of these unintended consequences could be avoided.