What is a Pharmacy Benefit Manager (PBM)?

Pharmacy Benefits Managers also referred to as PBMs, are third-party administrators of prescription-drug programs for payers, such as private insurers, and Medicare Part D plans.

PBMs act as a bridge between employers and their members, the drug manufacturers, pharmacies, and other health-related entities in the marketplace working to facilitate the best possible health outcomes at the lowest costs. Having a successful pharmacy benefit strategy and choosing the right PBM to meet an employer’s needs is critical to ensuring the success of a benefits plan, mitigating spend, and protecting the well-being of employees and their dependents.

What Functions do PBMs perform?

PBMs operate in the middle of the distribution chain for prescription drugs. PBMs objectives include:

  • Adjudication of pharmacy claims
  • Pharmacy network contracting, payment, and auditing
  • Mail order and specialty pharmacy access and administration
  • Rebate contracting, administration, and payments
  • Formulary or preferred drug list development and maintenance including establishing clinical editing, such as quantity limits, step therapies, prior authorization, and more
  • Clinical program management for adherence, duplicate therapy, opioid overutilization prevention, disease management, and other similar types of services
  • Member services, including a call center to answer employee and dependent questions and lend assistance with utilizing the pharmacy benefit
  • Reporting of overall pharmacy program metrics, trends, and statistics
  • Support appeals and grievances
  • Communications to members, pharmacies, and physicians to help educate, assist with decisions to drive to lower-cost alternatives and to bring overall awareness to help provide better health outcomes for the members
  • Assistance with compliance of State and Federal regulations

PBMs play a large role in assisting payers with effectively managing the overall pharmacy benefits program and obtaining the most value within these programs.

If you would like to learn more, please reach out to PillarRx at [email protected].