With prescription drug spend representing less than 10% of workers’ compensation costs, the role of Pharmacy Benefit Managers (PBMs) is often viewed as niche – and sometimes this role is not well understood.
As public discourse around PBMs in group health intensifies, it’s helpful to understand the goals and responsibilities of workers’ comp PBMs and the constraints under which they operate.
Put simply, PBMs manage pharmacy programs for the payers of workers’ comp claims. But their value goes far beyond transactional oversight. A good workers’ comp PBM will remove barriers to care, mitigate therapeutic risk, and create workflows that make it as easy as possible for injured workers to recover – guiding pharmacists, physicians, and claims professionals through a complex system where every decision must align with regulatory requirements and evidence-based care. These objectives reflect an expanded role versus group health, where this level of complexity simply doesn’t exist – and where PBMs may be focused on other priorities.
Let’s look at the important roles workers’ compensation PBMs play in the complex workers’ comp ecosystem:
Optimizing Utilization and Cost of Prescription Drug Therapy
Workers’ compensation PBMs serve as clinical and operational partners in optimizing prescription drug therapy, helping to ensure that injured workers get the right drugs, at the right time, and at the right cost for the payer. They apply strategies to help control costs, often proactively working with physicians and pharmacies to recommend therapeutically equivalent alternatives that may be less expensive, such as generics, without compromising clinical outcomes. But more importantly than that, PBMs help to ensure therapeutic safety.
Continue reading the article in full at the Healthesystems blog.
