Getting to Know How PBMs Work

Understanding how PBM work

Pharmacies and their employees benefit from knowing exactly what a pharmacy benefit management (PBM) is considering the significant role it plays in the United States’ health care system. Understanding their function and how to maximize a pharmacy’s relationship with them proves crucial in effective acquisition and selling of drugs.

What PBMs Do

PBMs participate in even your simple act of purchasing drugs. On your visit to a retail pharmacy, they forward your prescription to a PBM. The prescription is checked for eligibility, and once it’s been validated, the payment is duly assigned.

As for large pharmaceutical companies, they manage the rebates of drugs included in a formulary.
They have many more functions that benefit physicians, pharmacies, and their clients; primarily, they aim to give access to medication drugs at a minimum price.

Process of Elimination

Companies position themselves for advantage by seeking the counsel of pharmacy management consultants, according to Selecting a PBM, after all, requires detailed knowledge of how they work and whether they work correctly.

Here are a few of the basic things to focus on when getting to know them:

1. Differential pricing – Hidden charges should be made transparent to those it concerns. To determine whether they play fair, contact the networks under them and ask to compare the reimbursement rates to see if they’re the same.

2. Rebates – PBMs usually acquire this when they include the drug manufacturers’ product in a formulary and therefore increase profits from those drugs. Similar to transparency in differential pricing, you should require documents from them that details the calculation of the rebates.

3. Efficiency – The authorization process in prescribing drugs follows the guidelines of the health plan purchased. This is to ensure that the prescription contains only drugs covered by the health plan and approved by PBM for both cost-efficiency and quality. Otherwise, they must inform patients of additional payments.

4. Coordination – Formularies change, and when they do, PBMs should notify you in writing. Otherwise, patients might end up spending more on medicine no longer covered by their health plan due to this change.

The effort put into learning PBMs’ role in the health care system and how they should execute their work enables you to get the most out of them. Get to know each one well to identify the one that best suits your services.

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