What is a Pharmacy Benefit Manager (PBM)?


A Pharmacy Benefit Manager (or PBM) is an intermediary between virtually every element of today’s pharmacy benefits marketplace. While many people tend to assume that health insurance providers directly supply pharmacy benefits, in fact, PBMs do the majority of work for more than 80% of American employers.

A PBM could be hired by many different employers including corporate clients, labor unions, and health plans. Their role is to process claims relating to prescriptions and interface with manufacturers of medications.

In brief, therefore, a PBM is the connection between drug wholesalers, members, employers, drug companies, and pharmacies. They work to ensure optimal health outcomes for the best possible cost.

What Does A PBM Do?

A Pharmacy Benefit Manager has two primary objectives. The first is to curate various plan options for pharmacy prescription benefits while the second is to aid patients in achieving better health outcomes by giving them more access to the most appropriate medications for them. PBMs do this by working with wholesalers, drug manufacturers, plan sponsors, and pharmacies.

Pharmacy delivery software is an alternative to the PBM asnd is also a great way to accelerate the growth of an independent pharmacy/ PDS has been seen as a way to do so increasingly positively in recent years, for a very competitive rate comparatively.

Reducing Spending

A PBM will negotiate prices with an extensive network of mail or retail pharmacies so they can give employers and patients more access to drugs across several retail chains with competitive prices. A PBM will also offer large-scale clinical programs such as step therapy, prior authorizations, and quantity edits, to aid administrators of benefits plans to ensure appropriate safety precautions, savings opportunities, and usage of medications.

Furthermore, a PBM will frequently serve as an advisor for employers, providing recommendations and advice about different clinical programs and plan designs.

Increasing Medication Access

A PBM can increase access for patients to medications through direct negotiation with drug wholesalers or manufacturers. By negotiating quantity discounts from WAC (Wholesale Acquisition Cost) they can then pass the savings onto clients.

A Pharmacy Benefit Manager will also mitigate the rising costs of prescriptions while ensuring drugs are effectively administered to achieve the optimal result for the patient’s wellness and overall health. Through the establishment of an extensive network of pharmacies, a PBM can offer employers and patients alike better access to drugs across several retail chains.

Pharmacy Benefit Managers Work With Employers

Whenever employers sign contracts with a Pharmacy Benefit Manager to maintain and design their prescription benefits plan, typically the contract lasts for three years. Initially, the parties will work together to build an ideal plan by selecting from various co-payments, deductibles, clinical programs, and co-insurances.

Once the plan has been designed, it becomes the PBM’s responsibility to administer prescription benefits correctly and educate employees about the coverage available. Typically, PBMs offer member support via call centres to answer questions regarding co-payments for medications and in-network pharmacies.

PBMs take responsibility for four key components when handling prescription benefits plans for their employers:

  • Claims processing relating to prescription costs
  • Rebate reimbursement
  • Clinical programs
  • Carrying out ongoing drug use reviews with members

Employers are also heavily reliant on the Pharmacy Benefit Manager to keep them in the loop regarding information and trends about their plan’s performance and possible improvements that could be made.

It is therefore essential for employers to keep an ongoing and open dialogue with their Pharmacy Benefit Manager to make sure their members always get the best care at a cost that is highly competitive.

Clearly, a Pharmacy Benefit Manager has a vital role to play for all kinds of businesses, and with one on board, companies can ensure the best possible outcomes for their employees who are members of their prescription plan so they can maintain optimal health and well-being at all times at a cost-effective price.

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