Understanding PBMs
satya - 1/9/2022, 12:10:59 PM
Understanding Pharmacies and PBMs
Understanding Pharmacies and PBMs
satya - 1/9/2022, 12:11:05 PM
Understanding Pharmacies and PBMs
satya - 1/9/2022, 12:13:40 PM
From Pharmacists Association of NY: pssny
satya - 1/9/2022, 12:14:11 PM
Taken from the article below: PBM Basics
satya - 1/9/2022, 12:16:31 PM
From American Health Policy.org, A PDF
satya - 1/9/2022, 12:18:15 PM
Health Premiums, Deductibles, earnings, inflation
Show images for: Health Premiums, Deductibles, earnings, inflation
satya - 1/9/2022, 12:23:12 PM
As of 2019 (from 2009), looking up some graphs there
1. inflation 20%
2. wages 26%
3. Premiums 54%
4. deductibles 162%
satya - 1/9/2022, 12:30:00 PM
IT of PBMs
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
satya - 1/9/2022, 12:43:16 PM
Accumulators and PBMs Architecture
satya - 1/9/2022, 12:43:38 PM
An example of a PBM platform: Nirvana
satya - 1/9/2022, 1:14:32 PM
How do pharmacies check prior authorization?
How do pharmacies check prior authorization?
satya - 1/10/2022, 7:56:39 AM
Healthcare as a Supply Chain
satya - 1/10/2022, 8:45:49 AM
Patient, Pharmacy, PBM, and Payer interaction
satya - 1/10/2022, 3:26:59 PM
Integration aspects of Payers and PBMs
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
satya - 1/10/2022, 3:29:10 PM
Notes on item 4 in the diagram above
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,