For example, more PBMs are owning specialty pharmacies that can dispense specialty medications, which often are more profitable.
PBMs often restrict where health plan members can fill their specialty prescriptions by requiring them to fill their prescriptions at PBM-owned specialty pharmacies. In the past few years, specialty pharmacies have represented a larger share of the revenue generated by PBMs, a trend which is expected to grow.
Health systems often have a unique opportunity as both health plan sponsors and providers to work with PBMs, and can often employ their expertise and resources in beneficial ways.
For instance, pharmacy leaders can collaborate with the benefits team during negotiations with PBMs and play a crucial role. During a recent meeting, the pharmacy leaders explained why the PBM's copay accumulator program, which aims to manage usage by excluding copay assistance from a patient's deductible and out-of-pocket maximum, would not benefit the health system as it might affect patient adherence.
They can also improve formulary value by removing high-cost drugs and aligning formularies across settings. At a large nonprofit system in the South, the pharmacy team was able to review the PBMs' claims to identify possible opportunities for cost savings.
The VP of Pharmacy found providers had written a high number of prescriptions for a brand-name ointment. When she told providers about the generic version of the treatment, they system saw a decline in the number of brand-name prescriptions written and saved the hundreds of dollars per prescription.
But those are just some of the ways that health systems can interact with PBMs. Want to learn more about how your system can leverage their expertise to help lower benefit costs? Register now for a minute webinar tomorrow at 1 pm ET to learn much more. Current Article Pharmacy benefit managers, explained. Ask our experts a question on any topic in health care by visiting our member portal, AskAdvisory. November 13, Pharmacy benefit managers, explained. ET: Pharmacy Benefit Managers But there's a lot more going on behind the scenes between drug manufacturers, insurers, pharmacies, and, specifically, pharmacy benefit managers PBMs.
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Our response? Order Supplies. Rebate Sharing Insurance companies pay PBMs to manage drug costs and receive rebates from manufacturers. Pharmacy Spread Health plans are billed for amounts higher than they reimburse pharmacies upcharging , creating a "pharmacy spread.
Administrative Fees Administrative fees are fees charged by PBMs for the electronic processing of each claim. DIR Fees " Direct and indirect remuneration " fees are imposed on pharmacies after a patient sale that is not readily predictable.
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I Accept Show Purposes. Your Money. Personal Finance. Your Practice. Popular Courses. Insurance Health Insurance. Key Takeaways Pharmacy benefit managers negotiate with drug makers to secure a discount and then pass the cost savings onto insurers. These companies make money by up-charging the drugs or keeping some of the rebates. The biggest criticism of PMBs is the lack of transparency in their business models. Article Sources. Investopedia requires writers to use primary sources to support their work.
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