031128=PBM

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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AdvancePCS是美国最大的医疗改善服务提供商，提供最广泛的医疗卫生资源。该公司拥有7500万医疗计划会员（相当于每4个美国人中就有一个是该公司会员），和5万8千多药店网络链接，每年管理着280亿美元的医药支出。

其主要业务模式有：

Refill Prescriptions & Check Order Status 处方新购和查看订单状态 Lookup Drug Coverage & Pricing查找药品用途和价格信息 Prescription Plan Summary处方计划汇总 Locate a Pharmacy网上查找药店 Drug Dictionary药品词典

Drug to Drug Interaction Checker药品交叉反应检查工具 Online Drugstore在线药店 SpecialtyRx 专业处方

RxSavings Plan 处方费用节省服务 Online Forms 在线表格

Litigation Summary: 法律诉讼简要：

In March 2003, the Prescription Access Litigation (PAL) Project in collaboration with the American Federation of State, County and Municipal Employees (AFSCME), AFL-CIO, brought suit against the nation's four largest PBMs charging that they inflate prescription drug prices. The four PBMs named in this lawsuit are Advance PCS; Caremark Rx, Inc.; Express Scripts; and Medco Health. Through a variety of business practices, these four companies influence the choice of pharmaceuticals used by a substantial percentage of health plans and their members in the U.S. Together, they comprise over 80 percent of the PBM market, covering over 200 million Americans.

2003年3月的“处方获取诉讼”（PAL）项目，由美国联邦政府、州、县、市雇员协会（AFSCME）和AFL-CIO 联手以抬高处方药价格为由将全国最大的四家PBMs告上了法庭。卷入此案的四家被告是Advance PCS、Caremark Rx. Inc.、Express Scripts和Medco Health。 因业务量巨大，这四家公司已经实质影响到美国多数医保计划及其成员的用药选择，四家合计占有PBM市场80%以上，涉及2亿多美国人。

Because of their strong purchasing power, PBMs have been able to generate pricing margins and discounts at numerous points throughout the drug distribution system. The problem, the complaint alleges, is that they have consistently failed to pass the resulting savings along to health plans and their members-choosing instead to pocket the savings and increase their own profits. In so doing, this lawsuit charges, the four named PBMs have willfully contributed to escalating drug costs, and have failed in their fiduciary duty to those client health plans.

由于拥有强大的采购力，PBM已经能够在药品分销系统的许多环节创造利润和价差。投诉方宣称问题在于他们已经不再将医保计划及其成员因用药选择形成的费用节省贡献出来，而

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是代之以存入自家腰包和提高自身经营利润。因而，法庭判定四家被起诉的PBM故意抬高用药成本，辜负了客户的信任。

In addition, the four PBMs named in the complaint have refused to disclose the amount of the rebates that drug manufacturers pay PBMs for placement on their formularies. It is therefore impossible to know what percentage-if any-goes back to health plans and their members as savings. But PBMs clearly factor those rebates into their revenue projections. The complaint quotes PBM executives stating that manufacturer rebates have become essential to PBM profits.

另外，四家PBM拒绝披露药品生产企业为了让产品进入PBM药品清单而给予的折扣返点价值，因此，外界不可能知道健康计划组织及其成员到底能节省多大比例的费用，如果有的话。但PBM们清楚地把那些返点折扣收入计入了他们的营业收益，诉讼引述PBM高管们的陈述表明制药商的返点让利已经成为PBM利润的关键来源。

Finally, the complaint alleges that the PBMs fraudulently use the Average Wholesale Price (AWP) to inflate brand-name drug prices. AWPs, which are set by drug manufacturers, function as a kind of \artificially inflated. In addition, PBMs generally pay retail pharmacies less than what they charge the health plans. Because the PBMs consider the contracting relationship with retail pharmacies confidential, they refuse to divulge how much they pay pharmacies. The savings, the difference between the price charged health plans and the price paid pharmacies, or what is called \consumers, according to the complaint.

最后。投诉方宣称，PBM欺骗性地利用平均批发价格（AWP）抬高了品牌药品价格。平均批发价格（AWPs）是由制药商设定的一种“标价”，被广泛认为是人为抬高的药价。另外，PBM一般支付给零售商的费用要低于向医保计划组织收取的。PBM把和零售商的合同关系看成是机密，拒绝透露他们支付给药房的费用。按照投诉方的意思，节省部分，即向医保计划组织收取的药价和支付给药房的药价之间的差额，或者被称做“进销差价”，应该分派给医保计划组织和消费者。

PBMs claim that is what they do, but the complaint alleges that the PBMs usually pocket \with higher AWP prices-by listing those drugs on their formularies.

PBM申诉他们正式如此做的，但投诉方宣称PBM通常私吞了“进销差价”。“进销差价”在财务上给予PBM以动机去鼓励人们使用列入处方一览表具有更高“平均批发价格”的药品。

This lawsuit was brought under California's Unfair Competition Law. 这一诉讼案件已经由加州非公平竞争法介入裁定。 For more information:

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Ahaviah Glaser

(617) 275-2822

glaser@communitycatalyst.org

Medco Health Solutions, Inc.

We are the nation's largest pharmacy benefit manager, or PBM, based on our 2002 net revenues. We provide sophisticated programs and services for our clients and the members of their pharmacy benefit plans, as well as for the physicians and pharmacies the members use. We believe that our ability to consistently deliver programs and services that help our clients provide a high-quality, cost-effective prescription drug program to their members has made us a market leader.

依照2002年净收入，我们是全美最大的PBM。我们为客户及其药品福利计划会员和会员所用的医生药师提供最全面成熟的服务项目。我们相信我们能始终如一帮助客户向其会员提供高质量、符合成本-效益原则的处方药方案的能力使我们成为市场领先者。

We actively pursue initiatives to reduce the rate of increase in our clients' drug expenditures, referred to in our industry as \trend\to save members money and to improve the services we provide both our clients and their members. We continue to expand our pre-eminent home delivery business, which reduces drug costs for our clients and provides enhanced reliability and service to their members.

我们主动寻求创新产品以降低客户的“药品费用增长率”（即行内所谓“药品趋势”）来节省会员的钱，同时不断改善我们的服务。我们持续扩大业已成功的送货到家业务以减少客户的药品费用、对其会员提供增强的可靠性服务。 In 2002, our national network of home delivery pharmacies filled

approximately 82 million prescriptions, representing about 30% more than the number of prescriptions filled by the mail service operations of our three largest competitors combined. We seek to contain costs for our clients and their members by encouraging the prescribing of drugs on a plan's approved list of drugs, or \appropriate generic drugs through our generic education and substitution programs.

2002年，我们全国性的送药到家药店处理了8200万个处方，占同期其它3家竞争对手合计药品邮购业务的30%以上。我们通过对列入药品福利计划准入的药品清单（处方一览表）药品的使用，以及通过用药指南或替代项目服务引导的符合临床用药合理性的普药使用，为客户及其会员寻求成本限制手段。

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Our high-quality service, advanced technology and cost containment initiatives enabled us to limit the average drug trend for plans that include both retail and home delivery to 14.0% in each of 2000 and 2001 and 12.9% in 2002, compared to the national average of 17.3% in 2000, 15.7% in 2001 and an estimated 14.3% in 2002 as reported by the Centers for Medicare & Medicaid Services, or CMS.

我们的高质量服务、先进技术、和创新性成本限制手段使我们的覆盖了药品邮购和零售药店的药品福利计划对平均“药品趋势”的限制在2000、2001、2002分别达到了14%、14%、和12.9%，按Medicare和Medicaid服务中心的统计分别高于同期全国平均的17.3%、15.7%、和14.3%。

We have a large number of clients in each of the major industry segments, including Blue Cross/Blue Shield plans; managed care organizations; insurance carriers; third-party benefit plan administrators; employers; federal, state and local government agencies; and union-sponsored benefit plans. As of June 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. Over the last three years, our aggregate revenue from small to mid-size clients increased an average of approximately 39% per year, excluding the impact of acquisitions, to approximately $1.6 billion in 2002. 另外，我们通过分支机构满足中小客户的特殊需求。此前3年，来自于中小客户的营收每年按39%增长（不包含并购效益），2002年总值达16亿。

From 1998 to 2002, our net revenues increased on average approximately 26.4% per year. In 2002, we filled or processed approximately 548 million prescriptions, had net revenues of approximately $33 billion and net income of more than $360 million, and had earnings before interest income/expense, taxes, depreciation and amortization, or EBITDA, of approximately $886 million. Our net income is driven by our ability to earn rebates and negotiate favorable discounts on prescription drugs from pharmaceutical manufacturers, obtain competitive discounts from retail pharmacies, negotiate competitive client pricing, including rebate sharing terms, shift dispensing volumes from retail to home delivery and provide services in a cost-efficient manner.

1998至2002，净营业额按年均26.4%增长。2002年，我们处理了5.48亿个处方，营业额330亿，净营收3.6亿以上，未扣除利息、销售费用、税收、折旧及递延费用的收入8.86亿。我们的净收入是基于从生产商赢得返点和争得优惠（进货）

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折扣，从零售药店获得有利的销售折扣，与客户谈成有利的价格包括返点、共享条款、从零售到邮购的分销转移、以及按成本-效益方式提供服务。

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