Market channel developments:

  • PBMs seek to duplicate Medicare Part D success in the evolving healthcare reform marketplace
  • Increased focus on the management of complex patient types and biotherapeutics
  • Seeking to expand benefit management capabilities beyond pharmacy

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Find out how healthcare reform is impacting pharmacy benefit managers, click the link below:
Please find below more than 40 pharmacy benefit managers:
While the Express Scripts/Medco merger was substantial, a series of acquisitions over the course of several years has enabled SXC Health Solutions to grow exponentially and rebrand itself as "Catamaran".  Originally a company focused on claims processing technology used throughout the PBM industry, SXC began building its own PBM unit through executing a series of deals which ramped up considerably over the last 5 years:

  • Restat, a PBM, in 2013
  • HealthTrans, a discount card program/PBM services provider, 2012
  • Catalyst Health Solutions, a PBM, 2012 (rebranded company as "Catamaran")
  • MedMetrics Health Partners, a PBM, 2011
  • PtRx, a PBM/specialty pharmacy, 2011
  • MedfusionRx, a specialty pharmacy unit, 2010
  • National Medical Health Card Systems, a PBM/specialty pharmacy, 2008

With its healthcare IT attributes as a base, the company fortified itself with  PBM administration, mail order and specialty pharmacy capabilities --adding more covered lives and infrastructure with each acquisition along the way.  Through its PBM vendor deals with RegenceRx (a BCBS entity) and Cigna, the company had successfully extended its reach into the Blues and commercial managed care marketplaces.  United Healthcare has recently  acquired Catamaran and combined it with their Optum PBM business unit.
Collectively, the pharmacy benefits segment continues to be a healthcare industry change agent with ongoing, pivotal deals between the leading managed care companies, PBMs and retailers:

  • Catamaran is acquired by United Healthcare in 2015
  • RegenceRx deal outsources its PBM program to Catamaran, 2013
  • Costco launches its own PBM program, 2013
  • United HealthCare "insources" its PBM services away from Medco, 2013
  • Cigna deal outsources its PBM program to Catamaran, 2012
  • Walgreen Co. sells its PBM unit to CatalystRx, 2011
  • Aetna deal outsources its PBM to CVS Caremark, 2010
  • WellPoint sells its PBM unit to Express Scripts, 2009

While they are billed separately, pharmacy benefits have a direct impact on the care and cost performance of medical benefits.  This is even more pronounced when considered in Medicare and specialty pharmacy patient populations.  PBMs continue to innovate and drive care and cost performance for patients, payers and providers.  PBM
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Prime Therapeutics is a unique organization among PBMs and healthcare organizations.  It operates as a PBM partnership amoung 14 BlueCross BlueShield plans.  

The participating entities are BCBS of 

  • Alabama
  • Florida
  • Illinois
  • Kansas
  • Minnesota
  • Montana
  • Nebraska
  • New Mexico
  • North Carolina
  • North Dakota
  • Oklahoma
  • Texas
  • Wyoming

Initially starting as the pharmacy unit of BCBS Minnesota, it has collected additional stakeholders with the latest one being BCBS North Carolina.  

By the plans owning Prime Therapeutics, they get direct care/cost insights and integrated prescription plan administration they may not realize through a PBM separate from their organizations.  This includes operating two of its own mail order pharmacies and a specialty pharmacy unit.  Prime Therapeutics is able to apply leverage when dealing with retail pharmacy providers, pharmaceutical manufacturers (brand and generic) and other vendors.  The business model is flexible as it works with customers from their respective BCBS stakeholders as well as accounts who are not BCBS plan accounts.
The acquisition of Medco by Express Scripts in 2012 is the largest PBM merger to date. Express Scripts had purchased the PBM unit of WellPoint just three years prior.  Medco was larger than Express Scripts and the combination of the two gives the new organization exceptional scale.  This was successfully leveraged against Walgreen Co. in retail pharmacy network provider contract negotiations in 2013.
Click on the link below to find out how employers, insurance carriers, managed care organizations and PBMs are affected by specialty pharmacy benefit management:
John Baresky