What Exactly Is a PBM?

If your employer offers prescription medication benefits, you may think that you are getting your prescriptions directly through an insurance plan. The fact is that most health plans contract with a pharmacy benefits manager (PBM) to administer prescription drug benefits. So, what exactly is a PBM and what does it do for you? Simply stated, a PBM is a company that administers, or handles, the prescription drug benefit component of your employer’s health plan. A PBM processes and pays for your prescription drug claims and is responsible for assisting your employer with managing the prescription benefit. As the name implies, a PBM is in charge of administering prescription drug benefits, with the ultimate goal of providing plan members (you) with access to medications drugs while still keeping costs to a minimum.

The market is dominated by three major providers – Caremark, Express Scripts and Medco in no particular order. If you are using the major insurance carriers or third party administrators as your insurance you most likely have one of these companies on your insurance card. After that, you will see several other possibly familiar names – Walgreens, Pharmacare, Prime Therapeutics, MedImpact. Don’t forget that there are smaller regional PBM’s that have done quite well an exhausted list is hard to find.

To achieve the main objectives of their company, PBMs negotiate drug prices with pharmacies and establish a network of pharmacies that you can use to get your prescriptions filled, including PRxN mail-service pharmacy. PRxN PBM also assists in developing your Plan’s formulary or medication tiers, a list of medications covered under your Plan and their co-pay amounts. PRxN PBM helps to encourage the use of lower-cost medications, including generics, without compromising clinical effectiveness. PRxN PBM utilizes our clinical and managerial expertise to recommend and implement cost-containment measures, like requiring Prior Authorizations, Step Therapy Plans and Managed Drug/Dispensing Limits (refer to associated “Understanding…” articles). PRxN PBM uses rule-based programs to help reduce duplicate prescribing and medication usage. The pharmacists and Certified Pharmacy Technicians at PRxN PBM provide comprehensive clinical services to help you get the most clinical bang for your medication buck! PRxN’s PBM division is dedicated to helping you and your employer access the best therapy for the lowest cost, without sacrificing effectiveness.

Most people we speak with have no idea of any of the above information. Most would say that their prescriptions are handled by the insurance carrier. You are not alone! Many employers, including their human resource managers, have only a basic understanding of how PBMs make huge profits at the expense of beneficiaries like you. To protect your interests, you should know that PBM’s have a tremendous impact on U.S. health care decision-making because they influence more than 80 percent of drug plan coverage.

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