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The third annual Business Insurance directory of prescription benefit managers (PBMs) lists organizations that provide general prescription benefit management services, which are defined as services, combined in an integrated package, designed to control the types and distribution methods of prescriptions used by plan participants.
The package of services must include several of the following elements: pharmaceutical benefit design consulting, disease management of participants, prescription educational services for users or physicians, utilization review and claims processing. The PBM services must be provided on an unbundled basis (i.e. offered separately from other products and services the PBM may offer) and must be available to corporate and institutional employer clients other than third-party vendors.
Listings begin with the company name, address, phone number and fax number. The category 1996 revenues includes total gross revenues, gross revenues generated from PBM services and gross revenues from unbundled PBM services. The PBM clients section specifies total clients for which prescription benefit management services were provided, as well as the number of employer/group plans who contracted directly with the company in 1996.
Lives covered includes total group health plan lives (both eligible and active), active group health enrollees and active workers compensation enrollees in 1996. Active enrollees are defined as those participants who actually received prescriptions through the plan. Along with the number of active group health enrollees is a break-out indicating the percentage enrolled via direct contract with employers, through third-party vendors and through Medicare/Medicaid. The percentage of active workers compensation lives enrolled through direct contract with employers is also provided.
Retail network information includes the number of pharmacies who participate in the company's network. The percentage of prescriptions filled through mail-order services and the percentage of prescriptions filled with generic equivalents is listed next.
Staff information, given in full-time equivalents for 1996, details the total number of staff members, as well as the total number of professionals, assigned to prescription benefit management services (not including sales or marketing staff).
PBM services offered by the company are identified next, and services provided through a subcontracted organization are indicated with a footnote.
Network design specifies the type or types of formularies offered by the PBM. Open formularies allow patients to receive prescriptions from a relatively unrestricted list of drugs, whereas closed formularies impose limitations on the brand names/generic drugs which are available through a given plan. Restricted/customized formularies usually provide reduced coverage for drugs not specified in the formulary, and may allow the client to have some input in the design of the formulary.
The sections that follow indicate the types and names, if provided, of pharmacies participating in the network, the types of reports provided to the client and the service area and billing methods offered. If volume discounts are given to employer clients, it is so noted.
Principal officers and a contact person for readers seeking more information complete the listings.
Listings generated through responses to a Business Insurance questionnaire. The directory is published as an editorial service; there is no charge to be included. Although every effort is made to publish complete and accurate listings, BI is unable to verify all information.