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This article is a part of a series of The Many Paths of Pharmacy, which has 48 other pharmacy career paths.
Summary – Pharmacists in PBM
Pharmacy Benefit Managers (PBMs) are entities that have significant impact in determining total drug costs for health insurers. PBMs manage prescription drug benefits on behalf of health insurers, Medicare Part D drug plans, large employers, and numerous other paying entities. They are the liaison between the direct companies who negotiate pricing, rebates, and reimbursement with drug manufacturers and pharmacies to control total drug spend by all parties. There are 3 major PBMs that compromise about 78% of the market which include: Express Scripts, CVS Caremark, and OptumRx. Among some of the most common companies that hire pharmacy benefit managers are United Health, Blue Cross Blue Shield, Anthem and Duane Reade retail. The typical day working for a PBM pharmacist may vary greatly depending on the role of the pharmacist within the PBM.
For example, a typical day for a consultant pharmacist may include interacting with patients. Writing medications reports and sharing them with patients is a large part of this pharmacist’s everyday workflow. There are also pharmacists who work in the prior authorization or appeals department, reviewing entire patient case files to determine if a medication request should be overturned or upheld, in accordance with ever changing formulary and guidelines as well as discussion with Medical Directors. Some pharmacists utilize resources to educate patients on drug interactions. Other pharmacists may create utilization management guidelines, establish and maintain formularies, create new drug monographs, participate in pharmacy and therapeutics meetings, or work in supportive administrative and communication roles.
Some additional responsibilities of a PBM pharmacist may include, but are not limited to:
- Operate mail order
- Oversee patient compliance
- Perform drug utilization reviews
- Review prior authorization and appeal claims for overturn or uphold and process claims
- Maintain or create formularies and utilization guidelines
- Manage distribution among a network of pharmacies
- Provide specialty pharmacy services, such as consulting
- Support pharmacy and therapeutics committees
- Perform new drug reviews
- Analyze claims for proper adjudication
- Recommend trade or generic conversion strategies
- Cost of care analysis
- Pharmacy programs management
Requirements of a PBM Pharmacist
An active PharmD in the state of licensure is required; or equivalent of four years of external client facing support or related account management experience in a healthcare or Pharmacy Benefits Management (PBM) environment. Some positions may prefer completion of a ASHP-accredited Managed Care Pharmacy Residency and some pharmacists have also completed board certification and postgraduate year two (PGY2) pharmacy residency training). A vast understanding of healthcare analytics is preferred, but not required. Many pharmacists start out as contractors, who are then hired on full-time after a probation period. Although completion of a managed care residency is preferred, pharmacists can land positions in managed care by showcasing a broad understanding of the insurance marketplace and demonstrating a knack for numbers, business, and finance.
Salary of a PBM Pharmacist
The average annual pay for the PBM jobs category in the United States is $92,240 annually. Pharmacists may be paid hourly or salary, depending on the pay grade level. PBM jobs currently range anywhere from $58,000 which is a part of the 25th percentile to $119,500, being among the higher end of base pay in the 75th percentile across the United States. There are many opportunities for advancement based on skill level, with increased pay based on location and years of experience. Additionally, some pharmacy benefit managers may award their employees with annual bonuses that may be based partially on the company’s performance and partially on the individual’s performance.
Pros and Cons of Being a PBM Pharmacist
- The Pharmaceutical Care Management Association (PCMA) states that due to the necessity of PBMs to provide cost saving solutions, there has been a rise of pharmacist roles and is continuing to steadily grow.
- Job security, but it is dependent on demand and experience.
- There is usually a good work-life balance. The typical work week consists of an 8 hour workday Mon-Fri. Occasional or rotating weekends may also be possible.
- Many PBM positions are remote positions, especially in the pandemic and post-covid era.
- Mostly interaction with other pharmacists, medical directors and technicians
- opportunity to experience diverse roles even within the same company; opportunity for promotion to become a subject matter expert, supervisor, manager, and director.
- Traveling up to 25% in the Pharmacy Benefits Management role is possible, but not common.
- Overtime may be required during the 1st quarter of the year, which is considered a busy season. It may also be required when onboarding new clients or formularies or other “all hands on deck” circumstances.
- Pharmacists may be required to achieve a certain case rate.
- Many pharmacists start out as contractors before being hired on full-time, which may not be appealing for some people.
How to Stand Out as a PBM Pharmacist Job
Candidate Numerous pharmacists have worked in a variety of career paths before starting their PBM pharmacy career. When inquiring about PBM jobs, here are some tips to stand out:
- Completing a managed care residency may be the best way to start a career in PBM pharmacy without prior work experience.
- Network through professional pharmacy organizations. Remember that landing your first PBM job is often the hardest.
- Consider joining Academy of Managed Care Pharmacy (AMCP) as it can be a resourceful organization to meet new people and obtain new skills.
- Attend workshops and national conventions in order to expose yourself to different aspects of PBMs (e.g., AMCP Nexus).
- Show your ability to think critically, multitask and manage your time effectively, as well as adapt and learn new programs easily.
- Show your desire and eagerness to grow within the PBM role, and highlight any leadership capabilities.
- Become as proficient in Excel functions as you possibly can, such as pivot tables, vLookup, graphs, and tables.
Reviewed and Edited by: Eunice Lee, PharmD, Leighton Murri, PharmD
Alex is the Founder of The Happy PharmD. He loves anime, his family, and video games, but not in that order.