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Is Pharmacy Benefit Management Useful in WC?

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Term of the Day – Pharmacy Benefit Management

Pharmacy Benefit Managers (PBMs) are one of the most widely used services in the US for prescription drug administration. They are third party and contract with pharmacies to negotiate discounts and rebates with drug manufactures. Today, more than 210 million Americans receive drug benefits administered by PBMs.

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PBMs are responsible for processing and paying prescription drug claims and for maintaining the list of prescription drugs covered by a particular drug benefit plan. Because they have a larger pool for prescription drugs, they are able to negotiate discounts and rebates. Their services can also include things like tablet splitting and mail orders.

There are currently 60 or so PBMs in the US. Some are independently owned and others are divisions of bigger companies, chain drugs stores and managed care plans. They compete to win business by offering clients the ability to manage their drug spending and increase cost-effectiveness of their medications.

PBMs have many advantages, but each PBM uses the available services differently, depending on their client’s need. For example, PBMs monitor prescription safety across all pharmacy networks to catch potential drug interactions.

Just two days ago, CVS broke the news that they were removing Walgreen Co. from their Pharmacy Benefits Manager business, saying they had violated an existing agreement. They accuse Walgreens of seeking higher reimbursement rates when they already receive rates similar to those of other major national chains.

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James Moore

Raleigh, NC, United States

About The Author...

James founded a Workers’ Compensation consulting firm, J&L Risk Mgmt Consultants, Inc. in 1996. J&L’s mission is to reduce our clients’ Workers Compensation premiums by using time-tested techniques. J&L’s claims, premium, reserve and Experience Mod reviews have saved employers over $9.8 million in earned premiums over the last three years. J&L has saved numerous companies from bankruptcy proceedings as a result of insurance overpayments.

James has over 27 years of experience in insurance claims, audit, and underwriting, specializing in Workers’ Compensation. He has supervised, and managed the administration of Workers’ Compensation claims, and underwriting in over 45 states. His professional experience includes being the Director of Risk Management for the North Carolina School Boards Association. He created a very successful Workers’ Compensation Injury Rehabilitation Unit for school personnel.

James’s educational background, which centered on computer technology, culminated in earning a Masters of Business Administration (MBA); an Associate in Claims designation (AIC); and an Associate in Risk Management designation (ARM). He is a Chartered Financial Consultant (ChFC) and a licensed financial advisor. The NC Department of Insurance has certified him as an insurance instructor. He also possesses a Bachelors’ Degree in Actuarial Science.

LexisNexis has twice recognized his blog as one of the Top 25 Blogs on Workers’ Compensation. J&L has been listed in AM Best’s Preferred Providers Directory for Insurance Experts – Workers Compensation for over eight years. He recently won the prestigious Baucom Shine Lifetime Achievement Award for his volunteer contributions to the area of risk management and safety. James was recently named as an instructor for the prestigious Insurance Academy.

James is on the Board of Directors and Treasurer of the North Carolina Mid-State Safety Council. He has published two manuals on Workers’ Compensation and three different claims processing manuals. He has also written and has been quoted in numerous articles on reducing Workers’ Compensation costs for public and private employers. James publishes a weekly newsletter with 7,000 readers.

He currently possess press credentials and am invited to various national Workers Compensation conferences as a reporter.

James’s articles or interviews on Workers’ Compensation have appeared in the following publications or websites:

  • Risk and Insurance Management Society (RIMS)
  • Entrepreneur Magazine
  • Bloomberg Business News
  • WorkCompCentral.com
  • Claims Magazine
  • Risk & Insurance Magazine
  • Insurance Journal
  • Workers Compensation.com
  • LinkedIn, Twitter, Facebook and other social media sites
  • Various trade publications

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