Virtual Summit June 1: Deep Dive Into Prescription Digital Therapeutics Register Close

What Do Managed Care Pharmacists Do?

Pharmacists in managed health care organizations are responsible for the delivery of health care and prescription drug benefits to over 300 million Americans.

These organizations include health plans, pharmacy benefit management (PBM) companies, accountable care organizations (ACOs), and integrated delivery networks (IDNs). Pharmacists employed within these managed care organizations are responsible for a broad and diversified range of clinical, quality-oriented medication management services to ensure that patients within a population receive the appropriate medication therapy while managing healthcare costs.

What Do Managed Care Pharmacists Do?   

Managed care pharmacists work with other health care professionals to provide a range of services that ensure that patients—individuals served by a health plan or an ACO or IDN—receive appropriate medication therapies conveniently and cost-effectively. Pharmacists must possess both clinical skills and the ability to evaluate scientific evidence and apply these principles to patient care.

Pharmacists working in a managed care setting support a variety of services, including:

Managed care pharmacists are the people who help patients get the medication they need at a cost they can afford.

Developing and Implementing Evidence-Based Clinical Programs and MTM Programs  

 To enhance patient care, particularly for patients with chronic conditions whose quality of life depends on prescription medication therapies, managed care pharmacists design programs and provide services that:                                                                    

  • Evaluate scientific evidence to provide appropriate medications for a patient population. This review of evidence is conducted by a panel of pharmacists, physicians, and other health care professionals on a pharmacy and therapeutics committee (P&T).
  • Assess the effectiveness and safety of new treatments for diseases compared to standards of care.
  • Use evidence-based clinical and research data to create disease management and MTM programs that help patients manage their therapies to live healthier lives with their medical conditions. Pharmacists, physicians, and nurses work collaboratively to manage chronic and complex diseases by monitoring regimens, assisting with cost-saving strategies, and counseling patients to improve adherence.
  • Explore ways to manage patients with chronic conditions dependent on complex medication regimens.
  • Design and conduct outcomes-based research to assess real-world performance of medication therapies to inform medication management decisions.

Patient Safety Initiatives

Managed care pharmacists help ensure patient safety by researching and analyzing prescription claims data to identify actual and potential adverse drug reactions, communicating with prescribers and patients to help correct such problems, and educating prescribers about best practices associated with the use of prescription medications. These pharmacists design and administer:

  • Drug Utilization Review (DUR) programs: This process, whether at the time of adjudication or as a retrospective report, can identify potential prescription-related problems such as: drug/drug interactions; duplication of drugs; known allergies; sub- or super-therapeutic dosing; or inappropriate therapy.
  • Fraud, Waste, and Abuse Programs: Programs that review key drug classes (e.g., controlled substances) and monitor inappropriate use patterns.
  • Prior Authorization (PA or "Prior Auth") programs: An approval process that encourages proper use of medications and discourages inappropriate prescribing. All Prior Auth programs aim to ensure that patients receive the appropriate medications that will produce the best clinical outcomes at the lowest possible cost.
  • Monitoring programs: Some medications require lab-based monitoring or genomic testing (i.e., personalized medicine) for product selection or dosing. Monitoring programs ensure that medications are prescribed safely and appropriately, and patients receive the best possible outcome. Programs also involve monitoring patient regimens for drug interactions and medication adherence. 
  • Quality Assurance (QA) programs: Standard of care programs that enhance patient safety, improve how patients use medications, and ensure delivery of the highest quality and most current treatment options.

Communication and Collaboration with Patients, Prescribers, and Pharmacists

Managed care pharmacists design and use communication protocols, such as those used within a call center or MTM program, to ensure that there is an exchange of necessary information between patients, their prescribers, and their pharmacists. Communications are required to:

  • Notify physicians and other prescribers of drug safety alerts and clinical updates to assist them in evaluating patients' therapies.
  • Help physicians and other prescribers choose medications that will meet patients' needs and be eligible for coverage.
  • Provide patients with information on their individual prescription history through personalized reports.
  • Educate patients on their disease state and the medications they are taking or those being suggested by their physicians. Provide the point-of-care pharmacist with a complete patient profile and guidance on coverage issues to aid them in the delivery of patient care.
  • Help patients manage their health care and help prescribers address complex medication therapy questions.
  • Advise pharmacists in the community setting with important information about their patient's pharmacy benefits through effective prescription drug claims messaging, smart claims processing logic, and timely written notification about initiatives that may impact the experience at the pharmacy counter. 

Plan Benefit Design

Managed care pharmacists collaborate with other health care providers to design effective pharmacy benefit structures that serve a specific population's needs. The pharmacist uses clinical knowledge and practical experience to address such design matters as:

  • How to structure a formulary (the approved list of medications that a plan will cover) to encourage appropriate and cost-effective therapy. The level of patient cost-sharing for generic and preferred brand-name medications, as well as non-formulary medications, must also be established.
  • Whether a "participating" pharmacy network should be established;  if so, how expansive should the network of pharmacies (community, mail order, or online) be to serve the population properly; and what quality assurance criteria should participating pharmacies be expected to meet.
  • What criteria and procedures for drug utilization should be established to maximize patient safety and best outcomes.  This design must also ensure that patients receive the correct dosage of the right drug.
  • How to establish a specific plan design for specialty medications (i.e., high-cost medications that may require special handling, administration, or monitoring and are used to treat chronic, complex disease states). Plan designs may include limiting distribution, establishing specialty drug cost-shares, and implementing utilization management requirements.

Managing Quality and Cost Effectiveness of Medications

Managed care pharmacists help health plans, and other payers (e.g., employers, HMOs, trust funds, and Medicaid) evaluate and improve their pharmacy benefits by:

  • Encouraging prescribers to make clinically appropriate, cost-effective drug choices through utilization management criteria and formulary design.
  • Integrating quality improvement measurements that use patient experience and data to improve health outcomes.
  • Introducing system interventions that enhance the quality of patient care and reduce costs.
  • Using data to identify adherence and non-adherence with prescribing guidelines, and by creating measures for assessing physician performance, identify prescribing patterns and determine opportunities for improvement.
  • Ensuring a scientific evaluation of the cost of new medications by applying pharmacoeconomic principles.

Medication Distribution Process in the Managed Care Setting

The pharmacist in the managed care setting manages the medication distribution process through one of four approaches:

  • Through the managed care organization's pharmacies: Some managed care organizations, such as IDNs or health plans, operate their own pharmacies. Pharmacists working in these settings may oversee dispensing functions and provide MTM services to patients served by the pharmacy.
  • Through community pharmacies: Managed care organizations such as PBMs contract with broad networks of participating pharmacies to fill the prescriptions of their members. Managed care pharmacists may be expected to manage the pharmacy network, perform drug utilization reviews, minimize fraud and abuse, and initiate quality assurance programs to ensure that the organization's members have local access to high-quality, affordable pharmacy services.
  • Through mail order or online services: Some managed care organizations own or contract with mail order or online pharmacies. Managed care pharmacists manage these services to promote less-costly options and ensure quality outcomes.
  • Through collaboration with physicians and other health care professionals: Managed care organizations use technology and other resources to coordinate the medication distribution process to ensure patient safety. Pharmacists within managed care organizations review patients' medications to help safeguard against unintended side effects in new and existing prescriptions. In addition, they work with prescribers and other health care professionals to ensure that the medications prescribed are eligible for coverage and are affordable.