Pharmacy Benefit Managers (PBMs)

What are Pharmacy benefit managers (pbms)?

Reducing drug costs and improving convenience and safety

Pharmacy Benefit Managers, or PBMs, are companies that manage prescription drug benefits on behalf of health insurers, public and private employers, unions, and government programs. By negotiating directly with drug manufacturers and pharmacies to control drug spending, PBMs have a significant role in the healthcare system. Their primary goals are to reduce drug costs and improve convenience and safety for consumers, health plans, and employers.

PBMs have unique expertise navigating the specialized field of prescription drug benefits and delivery, working to promote affordable, safe and seamless access to medication and better outcomes for patients.

Here’s a breakdown of what PBMs do:

Negotiate Discounts

PBMs work with drug manufacturers to negotiate discounts and rebates for the health plans they manage. This can significantly lower the overall cost of medications.

Manage Pharmacy Networks

PBMs establish contracts with pharmacies to create networks. Pharmacies within these networks agree to certain terms, which often include offering competitive pricing to attract a larger customer base.

Determine Formularies

A formulary is a list of medications that a health plan covers. PBMs develop and manage these formularies, often including drugs that offer the best value.

Process Prescription Claims

When you visit a pharmacy, PBMs process and pay the claim. This process involves determining the payment amounts for the pharmacy, the insurer, and the patient.

Clinical Management Programs

PBMs offer programs and tools to improve medication adherence, reduce clinical errors, and promote patient health. This may include medication therapy management and disease management programs.

Specialty Pharmacy Services

Many PBMs provide or work with specialty pharmacies that handle complex and expensive drugs, typically for chronic conditions requiring special handling and administration.

In summary, PBMs are the unseen facilitators in the healthcare system, operating behind the scenes to ensure that the process from the doctor prescribing a medication to the patient receiving it is smooth, cost-effective, and safe.