PHARMACY BENEFIT MANAGER (PBM) FACT SHEET 药品利益管理机构介绍 PBM Background Facts: Pharmacy benefit managers — or \— are fiscal intermediaries that specialize in the administration and management of prescription benefit programs. PBMs contract with a range of clients, including HMOs, employers, unions, preferred provider organizations and other health plans.
背景知识：PBM是财务独立的从事处方药利益管理的中间机构。PBM的签约客户主要有：健康维护组织（HMOs）、雇主、行业协会或联盟、医疗服务机构、医保计划组织等。 PBMs purchase in huge volumes and have extensive networks of participating pharmacies. Bulk purchasing enables PBMs to negotiate rebates from drug
manufacturers and discounts from retail pharmacies. PBMs process hundreds-of-millions of pharmaceutical claims per year. In addition, they run mail-order fulfillment centers and provide other services to health plans.
PBMs的采购量非常巨大，其参与药店形成了广泛的网络。大批量采购使PBMs能够与制药企业就药品“销售返点”和与零售药店就“进货折扣”谈判。PBMs每年要处理数以亿计的药品需求申报（？）。另外，PBMs 还自营邮购中心，并对各类型的医保计划提供有针对性的服务。
PBMs also develop and manage drug formularies. Formularies are drug lists that PBMs develop and use to manage drug spending. By charging less for certain brands of drugs, PBM formularies steer health care consumers and their physicians into using particular drugs for particular therapeutic needs. The consumer pays a higher co-pay (and the health plan pays the PBM more) for drugs that are not in the \PBM's formulary. The health plan may provide no coverage for drugs that are not on the list.
PBMs 开发并管理“处方一览表”，PBMs开发和应用该表以管理药品消费。通过降低对使用确定品牌药品的付费，处方一览表引导医疗消费者及其医生按临床需要使用特定药品。消费者使用未被列入“处方一览表”的药品需支付较高的共摊费用。医疗保险一般都不采用未被列入该药品清单的药品。
Control of formularies gives PBMs tremendous influence with drug companies. The manufacturers typically compete — and pay a combination of rebates and fees — to secure most favorable placement on a formulary. Drug manufacturers typically pay PBMs: (i) access rebates for placement of products on the PBM's formulary; (ii) market share rebates for garnering higher market share than established targets; (iii) administrative fees for assembling data to verify market share results; and (iv) other fees and grants. 掌控“处方一览表”使PBMs对药品生产和流通企业拥有巨大影响力。制药企业通过有行业特色的竞争—返点折扣加付费—以获得其产品在药品清单上最有利的位置。制药商一般要对PBMs支付如下费用：1）“准入”的返点让利，以便使产品能够被列入PBM的药品清
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单；2）市场份额扩大的返点让利；3）PBMs收集数据以验证市场份额的管理费用；4）其他收费和基金赞助。
美国几家大的药品利益管理机构简要介绍
1．Medco Health is the nation's leading pharmacy benefit manager. Formerly known as Merck-Medco, Medco Health administers prescription drug benefits for over 62 million Americans，nearly one in four Americans.
Medco Health是美国处于领先地位的药品利益管理机构（PBM），其前身是Merck-Medco。Medco Health 管理着6200万美国人的处方药利益，几乎每4个美国人当中就有一个。
As of April 2003, the plans we administered for our clients covered 190 of the Fortune 500, including 52 of the Fortune 100, 12 of the country's 42 Blue Cross/Blue Shield plans, and several large managed care
organizations. In addition, our Systemed L.L.C. subsidiary capitalizes on our extensive PBM capabilities to meet the specific needs of small to mid-size clients.
截止到2003年4月，我们管理的客户中包括财富500强中的190家，100强中的52家，全美42个蓝盾/蓝十字医保计划中的12个。
Medco Health's educational programs and sophisticated information
systems link patients, pharmacists, and physicians, helping to ensure the appropriate use of prescription drugs for each individual based upon their health profile, best clinical practices, and benefit plan coverage. In 2002, Medco Health managed more than 537 million prescriptions through its 12 home delivery pharmacies and nationwide network of more than 58,000 retail pharmacies.
我们的教育项目和信息系统联接了病人、药师、医生以帮助参与者基于健康档案、最佳临床方案、和福利计划来合理使用处方药。我们通过12个拥有送药到家能力的中心药店及覆盖58000家零售药店的网络管理着5。37亿个处方。 Medco Health's services are designed to help control total healthcare costs, improve quality of care, and provide member satisfaction.
我们的服务目标是：总体控制医疗成本，改善医疗质量，提高会员满意度。 业务模式有
Prescriptions & benefits Prescription refill/renewal Prescription order status Price a medication Drug information
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Benefit highlights Envelopes & forms Locate a pharmacy Account summary
1.1 处方药及其福利：处方新购或更新、处方的订单状态、用药定价、药品信息、福利汇总、信封与表格（邮购与付款？新药申请？）、网上搜索药店，帐户信息。 Health & wellness Diseases & conditions Drug information Health toolbox Health news
1.2 健康与保健： 疾病与环境、药品信息、医药箱和医疗新闻等。
Nonprescription items Beauty Care Diabetic Health Care Home Health Nutrition Personal Care Remedies
1.3 非处方药项目：包括美容、糖尿病、医疗保健、家庭护理、营养、个人护理和药物疗法等
2．Pharmacy Services Group, Inc. (PSG) is an outcome based, full-service pharmacy benefit manager dedicated to the delivery of pharmaceuticals to a myriad of venues, including insurance companies, HMO's, PPO's, nursing homes and other institutional users, on a cost-effective, managed basis. 药店服务集团（PSG）是基于临床产出，专门针对药品供应服务，按成本-效果和管理式医疗的原则，提供全方位服务的药品利益管理机构，其用户包括保险公司、健康维护组织（HMO）、医疗服务组织（PPO）、家庭护理中心和其他机构用户。
Customized Clinical Services 客户化的临床服务 Claims Processing 医保申报处理 Client Reporting 客户报告
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Formulary Management 处方一览表管理 Drug Utilization Review 药品使用评价 Prior Authorization 预先批准（制度）
3．Express Scripts, Inc. is one of the largest pharmacy benefit management (PBM) companies in North America. The company provides PBM services to over 50 million members through facilities in eight states and Canada. Express Scripts serves thousands of client groups, including managed care organizations, insurance carriers, third-party administrators, employers and union-sponsored benefit plans. Express Scripts 是北美地区最大的药品利益管理机构（PHM）之一。该公司为美国八个州和加拿大的各类医疗机构5千多万会员提供PBM服务，包括管理式医疗组织、保险公司、第三方管理机构、雇主和联合资助的福利计划组织等。
主要业务模式
For Members 面向会员
Access plan information and prescription services and read detailed health and drug information. User name and password required. 获取医保计划的基本信息和处方服务，读取详细的健康医疗和药品信息，需要用户名和密码登录。 For Clients 面向客户
Use online tools to run reports, analyze plan designs or make real-time updates to member records. Digital certificate required. 使用在线工具运行报告，分析医保计划的设计或实时更新会员记录，需要数字认证。 For Producers 面向生产商
Download sales materials, create proposals and quotes and evaluate plan designs. User name and password required. 下载销售资料，创建建议书、引用并评估医保计划设计，需要用户名和密码。 For Pharmacists 面向药剂师
Receive instant online assistance, including solutions for rejected claims and payment advice. User name and password required. 接收即时在线决策辅助，包括处理拒付和付款建议的解决方案，需用户名和密码。 For Physicians 面向医生
Access important prescribing information and renew mail order prescriptions online. User name and password required. 获取重要的开具处方的信息，在线更新邮件订单处方，需要用户名和密码。
4．Caremark Rx, Inc., a Delaware Corporation, is one of the largest pharmaceutical services companies in the United States, with net revenue of approximately $6.81 billion for 2002. The Company's operations are conducted through Caremark Inc.,
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which provides pharmacy benefit management services and therapeutic
pharmaceutical services. These services are sold separately and together to assist corporations, insurance companies, unions, government employee groups and managed care organizations throughout the United States in delivering prescription drugs to their members in a cost-effective manner.
Caremark Rx，Inc. 是位于德拉华的一家美国最大的药品服务公司之一，2002年净收入达到大约68.1亿美元。该公司的运作是通过Caremark Inc.进行的，主要提供药品利益管理服务和疗效药服务。这些服务项目以单项和捆绑的方式提供给全美国的商业公司、保险公司、联盟组织、政府公务员组织以及管理式医疗组织，使这些客户能够给他们的会员提供基于成本-效果的处方药供应。
Caremark offers a complete range of innovative pharmaceutical, clinical, and administrative programs and services:
Caremark 提供一整套创新性药理、临床和管理方案及服务，包括：
? ? ? ? ? ? ? ? ? ? ? ? ?
Integrated prescription benefit programs including retail and mail pharmacy and benefit services
整合的处方（药）福利解决方案，包括零售、邮购药品、和福利。
National retail pharmacy network with electronic claims processing 全国性药店零售网络，具有电子申报处理功能。
Specialized therapeutic services centered on the delivery of biotech pharmaceuticals and related support services for patients nationwide 面向全国病人的以生物制药及相关支持服务为中心的专门治疗服务。 Clinical outcomes programs including disease state management 临床产出方案，包括疾病管理
Healthcare data management, analysis, and reporting 医疗数据管理、分析和报告
Prescription drug benefit plan design and consultation 处方药福利计划的设计和咨询
Related clinical programs such as formulary management, drug utilization review, retrospective and concurrent case management, physician profiling, and drug information for patients ? ? ?
相关临床解决方案，比如处方一览表管理、合理用药评价、复发性和并发性病症管理、医生档案和药品信息等
Paper claims administration 纸质申报管理
5.AdvancePCS is the nation's largest provider of health improvement services, offering the most extensive array of health care resources available from any single source. We serve more than 75 million health plan members - approximately 1 in 4 Americans - link to 58,000 pharmacies, and manage $28 billion annually in health care expenditures every year.
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