Methods of providing prescription drug benefits in health plans

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Abstract
Drug-benefit programs in health plans that offer varying degrees of risk to pharmacy providers are described. Administrators of health plans attempt to control the total cost of a drug benefit by controlling the cost per prescription, number of prescriptions, and administrative expenses. Specific ways to control these factors, such as through discounted product costs, patient copayments, and audits of prescribing practices, are described. Drug-benefit programs generally follow one of three models: fee-for-service contracts, hybrid fee-for-service risk contracts, and full-risk contracts. Examples of plans within each model are described. Full-risk contracts that provide drug benefits on a capitation basis put pharmacy providers at most risk of financial loss since physicians control prescribing. Pharmacists can control their risk by establishing a joint pharmacist and physician prescription fund that includes contract provisions limiting maximum losses, defining exceptions to the drug benefit, and paying close attention to payment schedules and characteristics of the program administrator. Antitrust issues associated with these new types of drug-benefit plans are described. Drug-benefit programs involving risk contracts can aid pharmacy practice by improving cash flow via negotiated prepayments, defining an enrolled patient population, and creating opportunities for generating additional revenue. Drug-benefit programs involving full-risk contracts and hybrid fee-for-service risk contracts will continue to develop, and understanding these models is the first step toward successful risk contracting by pharmacists.

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