The Pharmacy Benefit Brief | April 2022

Welcome to the Pharmacy Benefit Brief. This brief is your monthly snapshot of news from America’s prescription drug supply chain including pharmacy benefit managers, independent pharmacies, and drug manufacturers.


Covering effective drugs for the broad range of health care needs is critical. PBMs and health plan sponsors rely on the recommendations of Pharmacy and Therapeutics (P&T) committees when creating drug plan formularies, which are the drugs covered by a health plan, and to ensure any drug included for coverage is safe and effective. However, some recent state legislation would impair the work of P&T committees by interfering with their autonomy and clinical judgement.


Made up of independent physicians, pharmacists, and other clinical experts without conflicts of interest, P&T committees meet regularly to evaluate the clinical evidence on drugs and recommend their inclusion or exclusion from formularies. The drug recommendation process focuses on clinical considerations, including medical literature, Food and Drug Administration (FDA) approved prescribing information and safety data, and current therapeutic use guidelines.


Health plans and PBMs also rely on P&T committees to develop evidence-based guidelines used in drug management programs—including prior authorization and other utilization management tools—and to ensure that these programs support the quality of clinical care.


As policymakers, it is crucial to understand the importance of P&T committees and the critical role they play in effective formulary management for patients. Legislation that risks P&T committee autonomy and ability to function could prevent health plans from providing safe, quality, and cost-effective prescription drug benefits.


Imagine a patient at the pharmacy counter— the pharmacist inputs a patient’s prescription information and sends it electronically to the patient’s PBM. In real time and nearly instantaneously, the PBM checks the patient’s health and coverage background, including cost sharing and benefit information as well as drug utilization history, and alerts the pharmacist if it identifies any errors and possibly dangerous drug interactions. PBMs also provide physicians and patients tools to determine, at the point of prescribing, what drugs are covered under the patient’s insurance and what the cost sharing will be. Prescribers’ increased use of these real-time benefit tools should help eliminate surprises at the pharmacy counter.


Read more about some of the ways PBMs are innovating and deploying technology to improve patients’ quality of life and health outcomes.

Latest in Rx News

The newest episode of the Pharmacy Benefit Podcast (listen here) discusses recent Federal Trade Commission (FTC) interest in studying the PBM industry and highlights how PBMs harness competition to lower prescription drug costs.


A recent CBO report on prescription drug price and utilization trends both emphasized the value of pharmacy benefit managers (PBMs) and reveals that drug manufacturer pricing tactics are the root cause of high drug costs. 


An article in Forbes, Pharmacy Benefit Managers Are The Wrong Target In Biden’s Quest To Reduce Drug Prices, highlights evidence that brand drug manufacturer prices are unrelated to PBM-negotiated price concessions.  


What is a PBM? Watch the short video here.

America’s pharmacy benefit managers (PBMs). PBMs are advocates for consumers and health plans in the fight to keep prescription drugs accessible and affordable. PBMs administer prescription drug plans for 266 million Americans and have been able to achieve an overall stable cost trend for prescription drugs by innovating consumer-friendly, market-based tools that encourage competition among drug manufacturers and drugstores and incentivize consumers to take the most cost-effective, clinically appropriate medication.