EXPLANATION OF DIRECTORY TERMSPosted On: Aug. 2, 1998 12:00 AM CST
The fourth annual Business Insurance directory of prescription benefit managers (PBMs) lists organizations that provide general prescription benefit management services 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 and must be available to corporate and institutional employer clients other than third-party vendors.
Listings begin with the company name, address, phone number, fax number and Web site address. The category 1997 revenues includes total gross revenues, gross revenues generated from all PBM services and gross revenues from unbundled PBM services. The PBM clients section specifies the total number of clients, as well as the number of employer/group plans that contracted directly with the PBM in 1997.
Lives covered includes total group health plan lives, both eligible and active. Active enrollees are those participants who actually received prescriptions through the plan.
Active group health enrollees and active workers compensation enrollees in 1997 are also provided. 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 details the number of pharmacies that participate in the PBM's network. The percentage of prescriptions filled through mail-order services and the percentage of prescriptions filled with generic equivalents are listed next.
Staff information, given in full-time equivalents for 1997, details the total number of staff members assigned to prescription benefit management services. The total number of professional staff members is also provided, including the number of registered pharmacists on staff.
PBM services offered by the company are listed next. Services provided through a subcontracted organization are indicated with a footnote.
Network design specifies the 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 of pharmacies participating in the network, as well as the names of participating retail chains. The types of reports provided to the client, the service area and billing methods offered are also provided. If volume discounts are given to employer clients, it is noted.
Principal officers and a contact person for readers seeking more information complete the listings.
Listings are 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.