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ABOUT THE AUTHOR

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Dr. Siracuse is associate professor, Department of Pharmacy Sciences, School of Pharmacy and Health Professions, Creighton University. He received a BS in Pharmacy from the University of Connecticut, a PharmD from the University of Michigan, and an MS and PhD in Social and Administrative Pharmacy from the University of Minnesota. Dr. Siracuse completed a fellowship in pharmacoeconomics with the PRIME Institute at the University of Minnesota, Hoechst Marion Roussel, and Aetna Pharmacy Management. Dr. Siracuse teaches courses in U.S. health care systems, pharmacy practice management, and pharmacoeconomics. His research interests include economic and public policy issues related to pharmacoeconomics, patient safety, health information technology, pharmacy student issues and medication therapy management (MTM). Dr. Siracuse has earned the school’s scholarly achievement award and is a member of Creighton University’s Institutional Review Board. In 2011–2012, he participated in the Academic Leadership Fellows Program of the American Association of Colleges of Pharmacy.

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LEARNING OBJECTIVES

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LEARNING OBJECTIVES

After completing this chapter, readers should be able to

  1. Discuss the basic functions of a pharmacy benefit manager (PBM).

  2. Discuss financial relationships between PBMs and various stakeholders.

  3. Identify and discuss the various roles of pharmacists working for a PBM.

  4. List and discuss management and business skills required to be successful in the PBM industry.

  5. Discuss specialty pharmaceutical products and the unique characteristics of specialty pharmacy providers.

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SCENARIO

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The following employment opportunity was recently posted on a national employment Web site for insurance companies and PBMs:

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Position: Manager of Clinical Pharmacy for a national managed care company

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Description: This person will be responsible for leading and mentoring a formulary management team staff, managing daily formulary maintenance, and the development and maintenance of commercial and Medicare Part D formularies. The position will focus on commercial employers and set team directions, resolve problems, provide feedback and guidance to members of the team, and adopt departmental plans and priorities to address business and operational challenges. The individual will work internally with the clinical team and cross functional business areas in the development, maintenance, and implementation of formularies. This will generally be a self-directed environment with minimal guidance. Strong analytical and communication skills are required.

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Position function is researching, developing, and monitoring clinical pharmacy programs such as drug utilization review (DUR), prior authorization, health outcomes, disease state management, and specialty pharmacy programs. You will lead research for new prescription drugs or new indications for existing drugs. You are responsible for preparing drug review information for the medical director. Education and qualifications:

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  • Pharmacist with current license and minimum of 5 to 7 years of pharmacy experience

  • Three to five years of PBM experience

  • Two years working with commercial employer based contracts

  • Formulary management experience preferred

  • MBA and/or PharmD preferred

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To perform the previously described job successfully, the following competencies must be demonstrated:

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