Understanding PBMs

Understanding PBMs

Understanding Pharmacies and PBMs

Search for: Understanding Pharmacies and PBMs

Show images for: Understanding Pharmacies and PBMs

Taken from the article below: PBM Basics

From American Health Policy.org, A PDF

Show images for: Health Premiums, Deductibles, earnings, inflation

1. inflation 20%

2. wages 26%

3. Premiums 54%

4. deductibles 162%

1. Manage a retail network of pharmacies

2. Mail order capabilities

3. Drug quantity purchasing discounts

4. clinical analysis

5. eligibility tracking and determination

6. Claims adjudication

7. Payments to pharmacies

Show images for: Accumulators and PBMs Architecture

An example of a PBM platform: Nirvana

Show images for: PBM and Payer interaction

How do pharmacies check prior authorization?

Search for: How do pharmacies check prior authorization?

1. Eligibility

2. Plans and benefits

3. Other insurances carried by members(COBs)

4. Accumulator and deductible exchanges

5. Formularies exchange

6. Rebates

7. Medical claims (likely for step therapies and other drug interactions)

8. Single sign on

9. Network data to Payer for such things as Online Provider Directories

1. The member cost share due to deductibles spent is exchanged off line, althought as soon as such a spend event occurs.

2. This means at the POS PBM directly answers the member responsibility

3. Similarly eligibility, and prior auths are also stored at PBM allowing PBM to answer the POS call from a pharmacy,