k m v r1 r1 16~20 (2009) J. Korean Academy of Managed Care Pharmacy Vol. 1, No. 1 Pharmacy Benefit Management iç 1# x sƒ, 1 w w w Overview on Pharmacy Benefit Management in USA Kyung Eob ChoiGand Hyun Taek Shin 1# Healthcare Review and Assessment Committee, Health Insurance Review and Assessment Service 1 College of Pharmacy, Sookmyung Women's University n p n, r p p t p p ~r ov pp nk p r, vr l qv d r Š p. p ~rl pk p q l l pk p ov pk lr p o l p, k p } sr o ˆp t p. p ~r nm qm r vop q q l p p ~rm p pp qp pql ql o prkp pr pp p kr l ˆp rl pl pk l l( n ql kr l) ~ o p. qp pql ql } kr ˆ(prescription drug benefit)p t q p l p pk l nv m l pk p v rp q p } kr v p v p p } kr ˆp rp p pp n mn k. p n 1973 HMO (Health Maintenance Organization) p rr qv r o k p qop n- rp n p p d r " q managed care p l p MCO (Managed Care Organization) q mp p q p kr prp q k l kr m(pharmacy benefit management)p re m. MCO p kr m l r rp # Correspondence to Hyun Taek Shin T: 02-710-9575 F: 02-716-9404 E: shingo@sdic.sookmyung.ac.kr (PBM, Pharmacy Benefit Manager)l n ql } kr l oˆ lp p PBM p k q(medicare Medicaid ) d p o o l d qp q m. p n, r v p p lr o kr rr r k r} p o, k r tp q r}p e p. p r}p r r qv d r p r r r k rl managed care p r n lp p. n p n, r p nml pl r t p r rp v rp kv managed care q qr lp k pl e r r ˆ rnp kr ml l rn r rp p. n nm p r l p k r managed care rl p r rrp p p p p ep. pl l l 1970 p managed care p l r m PBM (Pharmacy Benefit Manangement Manager)l q. 1. PBM (Pharmacy Benefit Management) p n, 1965 eq r vop (Medicaid, Medicare ) 1980 v r p q v p 80%, q 20% r (indemnity insurance)p plp 1973 16
Pharmacy Benefit Managementp n 17 rr l (HMO Act)p m p 1980 l d r q(, po k )l qrr o (financial risk)p Š managed care ~, v MCO p e l q sp p ~ l. p 1990 v qp p n v l np v e qrk l e lp p ˆ o q p dpnp rr Š(utilization review), v (quality measurement) p managed care p, sp l~ q m. p managed care p rp, po v p lrl rn l mp p rp kr l rn l m. p l r~ p v r p v mp s p ~ m managed care p pe pp k p managed care p rnp ll j k rmp p k pep l. l q p l n 4} 6 p p pv r~ p p 85% managed care rn p l p pp, nr vr p dp r p p managed care rp l p p. } kr managed care rn PBM (Pharmacy Benefit Management) p n, v kp PBMl r 10%l 40%p kr r p rm p p. p p l p PBMp managed care l nr vr p d r p pt rp v r l m r p. n nm p q p p l l v l np p rp k managed care e q o k m p pp p. 2. PBM (Pharmacy Benefit Manager)» xy 1973 l (HMO Act)p rr p, nm MCO p }pl, pop np vtrp mp p e kr r~ np 5%l m. p 1980 v MCO p q~ k l kr d r mp 1980 t v r 1 (first generation) PBM p p MCOl n rp d r m. l PBMp op 1970 l l q q PBMp CVS Caremark Medco Health Solutionp r Prescription Card Service (PCS)m Medco Containment Servicep. p PBM p }pl r rp vlk (pharmacy network)p l o l kr p d n } sr d r e q mp p managed care p l rp kr d r vp PBMp q m. kr d p rp rp, nm p PBM p PBM (Express Scriptsm Diversified Pharmaceutical Service) 1980 t l sp MCOl p l. p p } PBM l 1990 l rl l ˆ p PBM p l d qp lp p r l PBM p p p lp pl q k 50 p PBM p nm p p k r pp t o 10 p PBMp eqp 90% ro d lp r l < 1>. p PBM lp q p p q( ) n ql kr d oˆ rm q r~p 95% p, r~ } kp 70% p PBMl p ppp lt p. 3. PBM (Pharmacy Benefit Manager)» w PBM p k qm kp l kr oˆ pp e rk r p p p tn pop p. n } sr d(mail order pharmacy service) n pl PBM p o l vr, } sr d r p f p tn p lp ˆom. Table 1. PBM p p o (2006 2007 vp p ) o Pharmacy Benefit Manager o ( o:100 ) 1 CVS Caremark 82 2 Medco Health Solutions 71 3 Express Scripts, Inc. 51 4 Wellpoint Pharmacy Management 36 5 MedImpact 21 6 Prime Therapeutics 13 < }> Managed Care Pharmacy Practice 2nd Edition (2009) 99 pv
18 JKAMCP November 2009 Vol. 1 No. 1 PBMp tn p 1) ~ pk (formulary )p ov, 2) kr ~ l e v, 3) vlk p p r r pk n (DUR, Drug Utilizaton Review) nm, 4) v nm, 5) r r kp nš ~sr nm, 6) rk m p p k nm, 7) n } sr d r k. p k t tn p qp t l kp q q n o l p pk p (formulary management)m rr } pk p rl m q r r DUR p nmp. PBMp q tn p l vlk l m p, ee p kr ~ e (online, real-time claim adjudication) edšp q rr } sr pl v k r r DUR p nmp p. 1990 r rr l (OBRA 90)l vlk l n ql } sr l DURp p l PBM p vlk o, vlk p POS(Point Of Sale) edš PBMp er(concurrent) DURedŠp l r r DUR p, nm l < 1>. p kr p ~ r l ee r r DUR p vlk p k l, q rm } rl kr Š rm k v p r l l mp k qp k l }pp ep p n k (pharmaceutical care)p p ˆ e. q p q p p } rp l vlk p l pv k l k p rp qp, k (k k ) p Žk, } Š(instore DURedŠ, v k edšl ˆq DURed Šl p } p krr ) ee, r p rp kr ~ o PBMl } r r r, PBMp ProDUR (Concurrent DUR C-DURp ) e dšl p rp r(k t, qn ) l (tql ) e p f ptr krr rp ~ } sr r p < 2>. PBM vlk p l p p ee p r r DUR p rr } sr rl m p f v rp rv kp kr r p p lr mp p PBM (Medco Health Solution)p p DUR p 2007 7% p p kr r pl p. p p p PBM p p n p PBM~ m l e l r p < 2>m. 3. PBM (Pharmacy Benefit Manager) m lp PBM ll p p vl vrrp m p t kr d r p nmp p p, dp vp q o p. p PBM p p p p dp p URAC (www.urac.org)p 3 l t (PBM Accreditation Standards)p rn, ee l pv p. q o p PBM p URACp Fig. 1. PBMp r r DUR p nm e.
Pharmacy Benefit Managementp n 19 Fig. 2. PBM pql vlk p } sr r. Table. 2. PBMp tn e l 1 k kr lp l p e l ee v kp e e r 2 ~sr (generic substitution) 3 kr p (rebates) 4 vq (copayments/coinsurance) 5 ~ pk vr (formulary management) pvp kp p pvl k q oˆl t o n p qn p. p PBMp v ~ p p p p JCAHO (www.jcaho.org) 3 pvp ~ m p rp k URACp tp n p PBMp t r l d ee n, p ee pp 1s p l ql rn vž r e l p pk vr v pp mp n 6 v (disease management programs) 7 } kl n d (mail service prescriptions) ee v kp rp 8 ee, m p kr ~ e (real-time, online claim adjudication) 9 r r pk n (prospective drug utilization review) nm ee v kp (p } p } p o edšp nm pp) l l mv n. 4. PBM (Pharmacy Benefit Management) ù w l p PBMp l r nm p
20 JKAMCP November 2009 Vol. 1 No. 1 n p PBM (Pharmacy Benefit Management)p managed care e o k p o v kp p p l l. n p p vlk p p k p m, do o m o p p pp n r p kr rp p o e v, r m p PBMp m n m pv p l. p q v s ov pp l qp pp st o l p q qro p l qrp n- rp n q managed care p p p }p p. pr n l dr q, q q l n- rp vrp p d r p qr nmp p p r k p. p n, kr vlk p PBMl p p lv pp p PBM p pq PBM (URAC )p l m e p. p p PBM p dr q kr oˆ q, q seˆ o l q ep q p ep k, n kr prp p kp k p. vlk v m m o p rp p p do p q l pk n p krp eˆ o p lp PBM (Medco Health Solutions Inc.) l, nm p DURedŠp p l, nm p ep n rp. n p PBMp p p v p PBM l l rn sp p n, reˆ p m n kr r pk p lp v l l p p p. p p managed care p e p PBMp n l peˆ n, q p q p p p } kr, r e l pk nl rr, } srvoedš nml p p p } p km v kp p. n p PBM (Pharmacy Benefit Management) l p PBMp r(kr p v r d) vr dm n p o managed care p e p q q, dr q, q p r qrr o p (risk-sharing) p f r~ p p dp l r kr rm p p. q n rp q p vp pl kr p np v p qrl k p v l } pp q, q, dr q p k l p l p l r p l p. n p q kr np p pv p p n, kp vr o pk p rr q l r p kr v pv m rv kp p r l p p. v, PBM r pl o Right use of one dollar prescription drug can save 6 dollars of healthcare cost. l p p e n p p r. pr n l PBMp o ql sp kp jq rp pk qr p pp p m, reˆ el kp q jq DURr e pp v edšp p, qtep PBMp reˆ, rk l, k v qr e v p Š pp p. p Š ol kp p k m(managed care pharmacy)p r l k (pharmaceutical care) p ql e} q ov o Œq p ppp lp pp p p p r p v p q ˆp pp p. *** p np p p l Œ (q) pk r}l pk r}l 4 1 (2009)p p PBM r (e ˆ)m p p v 4 1 (2009)p PBM (e ˆ)p np q v pp š *** š x 1. Navarro RP. : Managed Care Pharmacy Practice 2nd edition, Jones and Bartlett Publishers (2009). 2. Academy of Managed Care Pharmacy (AMCP) : available at: www.amcp.org. 3. Korean Academy of Manage Care Pharmacy (KAMCP) : available at: www.kamcp.or.kr.