Pharmacy benefit managers (PBMs) already administer Rx benefits for most employers and several Medicaid programs. Medicare’s voluntary prescription drug benefit, set to begin in 2006, creates a huge new market opportunity for PBMs. However, the Medicare drug benefit will also create significant new challenges to PBMs and other organizations bidding to cover Medicare beneficiaries. And the PBM industry is under increasing scrutiny by regulators and state attorneys general.
Bob Atlas, a leading managed care consultant and former president of The Lewin Group, explores these business challenges in an excellent new article in Health Affairs. Atlas examines the history and business practices of PBMs and the role PBMs may play in the new Medicare drug benefit. He observes that PBMs appear to have “both the capacity and the technical capability to deliver the benefits, although many PBMs will likely partner with others more comfortable taking risk: insurers or the government itself.”