Regulation of the Prescription Drug Benefit
Where We Stand:
The Academy of Managed Care Pharmacy believes that government should encourage an environment in which pharmacists working within managed care organizations, including pharmaceutical benefit management companies, can continue to develop innovative and integrated strategies to manage prescription drug benefits for a given patient population. A properly developed and managed pharmacy benefit not only maximizes positive patient outcomes, but also helps to maintain the affordability of the prescription drug benefit itself. It is essential that managed care pharmacists have broad latitude to exercise their professional judgment in structuring drug benefit programs. Onerous regulations can prevent managed care organizations from properly reacting to clinical and economic realities (e.g., safety issues or encouraging the use of a less expensive, yet therapeutically equivalent alternative) patient noncompliance with drug regimens, and other practical considerations.
The Academy opposes statutory and regulatory proposals that unduly restrict the ability of pharmacists working within managed care organizations from utilizing tools and services that are essential for the management of a prescription drug benefit. These types of proposals are objectionable if they go beyond procedural protections and enter an arena traditionally within the purview, expertise, and experience of health care professionals. The imposition of such restrictions potentially incapacitate the ability of managed care pharmacists to consider the range of clinical, legal, quality‐of‐life, safety, and pharmacoeconomic factors which form the basis for the design and implementation of effective drug benefit strategies and programs. The goals of these strategies and programs are to improve the delivery of patient‐oriented pharmaceutical care and restrain the increases in the cost of prescription drugs.
Examples of strategies and programs that pharmacy benefit managers have developed and successfully implemented include drug utilization review, formulary management, and disease and health management. These programs encourage the appropriate, safe, and effective use of prescription drugs to improve patient outcomes. Proposals that would limit the flexibility of managed care organizations, including pharmacy benefit managers, to use existing and develop new strategies could have unintended consequences. Unnecessary or overly burdensome regulatory restrictions could place patients at risk and increase the cost of health care. The result could compromise the availability and affordability of the prescription drug benefit. The benefits would be reduced or made available to a smaller patient population, or the benefit itself would be eliminated.
The ability to develop programs and utilize tools and services to manage prescription drug benefits helps to assure that the benefit is affordable for both patients and purchasers. It further helps assure the benefit is delivered in a manner designed to optimize achieving therapeutic outcomes desired by patients and the health care professionals responsible for their care. Providing appropriate flexibility will mean that pharmacists and other health care professionals can respond to a complex and continually changing health care delivery system.
AMCP Where We Stand series: https://www.amcp.org/policy-advocacy/policy-advocacy-focus-areas/where-we-stand-position-statements
Revised by the AMCP Board of Directors, October 2014
Revised by the AMCP Board of Directors, June 2010
Approved by the AMCP Board of Directors, April 2002