Rumore MM, Vogenberg FR. PBM P&T Practices: The HEAT Initiative Is Gaining Momentum. P T. 2017;42(5):330-335.
The origins of the modern P&T committee lie in hospital-based drug management practices. As managed care evolved and pharmacy benefit management (PBM) emerged through Medicaid and commercial insurance growth, many former hospital pharmacists moved into the growing variety of managed care pharmacy positions.1
The PBM industry has come a long way from its start in the 1960s handling computerized prescription claim adjudication using plastic benefit cards. Its current role focuses on the reduction of pharmacy expenditures among plan sponsors with concurrent improvement in health outcomes. Since 1998, when the Department of Justice (DOJ) first investigated their effectiveness in doing that, PBMs have faced increased scrutiny for a lack of transparency, with some suggesting they are partly to blame for skyrocketing prescription drug prices. As the discourse on prescription drug prices in the United States intensifies, PBMs find themselves in the midst of a major shake-up of the industry regarding antitrust and antikickback laws, standards imposed by the Employee Retirement Income Security Act of 1974 (ERISA), and consumer fraud. Over the past two years, PBMs have fallen into the crosshairs of government investigations about the high cost of pharmaceuticals, with an emphasis on potential health care fraud involving contractual relationships between drug manufacturers and PBMs.
In 2016, PBMs managed pharmacy benefits for 266 million Americans.2 While there are approximately 60 PBMs in the U.S., the three largest—Express Scripts (formerly Medco Health Solutions), CVS Caremark, and OptumRx—comprise 62% of the market,3 accounting for approximately four billion retail prescriptions,4,5 and have enjoyed great profitability. PBMs serve as third-party administrators of prescription programs for commercial health plans, self-insured employer plans, Medicare Part D plans, the Federal Employees Health Benefits Program, and state government employee plans. They play a critical role in the prescription drug supply chain by performing a number of P&T-related activities, such as developing, maintaining, and enforcing the formulary (Table 1). This article specifically focuses on PBM-based P&T and formulary practices.
Read the full article here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5398626/