Regulation of the Prescription Drug Benefit
Where We Stand:
The Academy of Managed Care Pharmacy (AMCP) believes that the 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 effectively managing prescription drug benefits because they can restrict efforts needed to properly react to clinical and economic realities. For example, placing restrictions on formulary and utilization management activities can limit a plan’s ability to modify formularies or implement prior authorization requirements to address new clinical findings, newly approved medications, or the availability of less expensive therapeutic alternatives. These capabilities are important in order to provide a safe, clinically effective, and valuable prescription benefit that helps to moderate costs for individuals and employers purchasing prescription drug benefits.
AMCP 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 programs are managed by pharmacists and other health professionals with expertise in managed care. The imposition of such restrictions potentially incapacitates the ability of managed care pharmacists and other health professionals 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 utilize evidence-based medication use strategies that improve access to medication, enhance patient and population health outcomes, and ensure the appropriate use of health care dollars. 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. Though often well-intentioned, unnecessary or overly burdensome regulatory restrictions could place patients at risk and increase the cost of health care. The result could compromise the safety, availability, and affordability of the prescription drug benefit. This would lessen patient safeguards, increase costs and, in turn, 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 safe and affordable for 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.
See also:
- AMCP Where We Stand series: https://www.amcp.org/policy-advocacy/policy-resource-center/where-we-stand-position-statements
Revised by the AMCP Board of Directors, October 2021
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